Service access models: a way forward. Resource guide for community health services

Transcription

1 Service access models: a way forward Resource guide for community health services

2 Published by the Primary Health Branch Victorian Government Department of Human Services Melbourne, Victoria December 2006 Copyright State of Victoria 2006 This publication is copyright, no part may be reproduced by any process except in accordance with the provisions of the Copyright Act This resource was developed as part of the state-wide Service Coordination Industry Consultant initiative, funded by the Primary Health Branch, Department of Human Services. This document may also be downloaded from the Department of Human Services web site at: Authorised by the State Government of Victoria, 50 Lonsdale Street, Melbourne. Printed by Dogsbody Publishing and TMP

3 Acknowledgments This resource guide is an initiative of the Service Coordination Industry Consultant (Community Health), funded by the Victorian Department of Human Services Community and Women s Health Program. The guide is the culmination of several years innovative and dedicated work by many, in addition to more recent contributions. Key Community Health Service (CHS) managers and staff, Primary Care Partnership staff and consultants have made significant contributions to the design and establishment of quality service access models. The authors are indebted to all who assisted, both directly and indirectly, and particularly acknowledge the following for their generous, visionary input and guidance: Specific community health services and other organisations: Bairnsdale CHS Ballarat CHS Ballarat Health Services Banyule CHS Bass Coast CHS Bentleigh Bayside CHS Bundoora Extended Care Centre Cardinia-Casey CHS Caulfield CHS and Caulfield General Medical Centre Cobram District Health Service Dunmunkle Health Service East Grampians CH Eastern Access CH Gippsland Lakes CHS Grampians CHS Greater Dandenong CHS Inner East CHS Inner South CHS ISIS Primary Care Knox CHS La Trobe CHS Manningham CHS Monashlink Moreland CHS Nillumbik CHS North Yarra CHS Peninsula CHS Ranges CHS Southern Health Primary Care Yarra Valley CHS Whitehorse CHS Victoria s Primary Care Partnerships Juliet Frizzell, Effective Change Pty Ltd Ro Saxon, HDG Consulting Deb Warren, Community Services Consultant and Trainer Service Coordination Industry Consultant Steering Committee members: Meredith Kefford Samara Cox Kim Marr Heather Russell Jonathon Brown Philomena Sawyer Jim Killeen Carina Martin Ben Leigh Karen Oliver Carol Fountain Anna Fletcher Mary-Lou Proppe Helen Wade Bronwyn Fleming Lyn McKay Chair Manager, Community & Women s Health Program, Department of Human Services Community & Women s Health Program, Department of Human Services Primary Health Integration Unit, Primary Health Branch, Department of Human Services Home And Community Care and Assessment Unit, Aged Care Branch, Department of Human Services Eastern Metropolitan Region, Department of Human Services Hume Region, Department of Human Services Whitehorse CHS Ranges CHS Bass Coast CHS and La Trobe CHS Bellarine CHS Southern Health Barwon Health Banyule Nillumbik Primary Care Alliance Central Highlands PCP Service Coordination Industry Consultant Service Coordination Industry Consultant Project Worker Jonathan Pietsch and Inner East PCP for Lyn McKay s secondment Jim Killeen and Whitehorse CHS Board of Management and Management team Department of Human Services Community and Women s Health Program

4 Service Access Models: A Way Forward Resource Guide for Community Health Services 2 Contents Acknowledgments... 1 About this guide... 3 Part 1. Introduction Service Coordination Service access Service access terminology Context System context Consumer experience... 8 Part 2 Service access models Methodology for identifying the models Core components of the models Structure Function Resourcing Identified service access models The way forward...18 Part 3 Principles for model selection Factors driving change and influencing model selection Desirable Service Coordination outcomes Review of current system or models Supportive organisation features Model consideration...27 Part 4 Implementation Learning from experience Change leadership Determining the services and functions in scope Implementing change: keys for success Challenges Overview of a suggested change management process...37 Part 5 Evaluation Key evaluation considerations Types of evaluations Evaluation planning framework Evaluation planning keys Evaluation tools...44 Glossary Appendix 1 Service Coordination Product Map...52 Appendix 2 Additional policy context from a Service Coordination perspective...53 Appendix 3 Hypothetical structural designs...59 Appendix 4 Service access models comparative chart...61 Appendix 5 Staffing options comparative chart...66 Appendix 6 Suggested change management process...70

5 Service Access Models: A Way Forward Resource Guide for Community Health Services 3 About this guide Integrated service access models support efficient, effective and consistent consumer access to services. They also reflect individual organisation characteristics and local circumstances, and further embed community health within the service system. This resource guide has been developed to assist Community Health Service (CHS) managers to review, select, implement and evaluate service access models. It outlines the importance of service access models in supporting Service Coordination and provides a summary of the context. It identifies various service access models and describes and compares benefits and challenges associated with each. Factors influencing the selection of a service access model and the desirable outcomes an effective service access system can support are articulated. It includes implementation and change management strategies, as well as evaluation methodologies. The accompanying Service access models: Toolkit consists of sample documents, tools and templates to facilitate change management, and support the review, selection and evaluation of organisation service access systems. If you are new to service access models or wish to review the associated context, please start at Part 1. If you wish to consider various service access models and their core components, please go to Part 2. If you wish to review current service access practice or select a service access model, please go to Part 3. If you wish to implement a service access system, please go to Part 4. If you with to evaluate a service access model, please go to Part 5. If you wish to consider or use sample tools, policies or templates, please refer to the Toolkit in the accompanying CD. This resource guide complements broader Service Coordination resources. These include the Victorian Service Coordination Practice Manual (including the Good Practice Guide for Practitioners and Continuous Improvement Framework), local PPPS (Practices, Process, Protocols and Systems) manuals, the Service Coordination Tool Templates 2006 SCTT) 2006, and the Service Coordination Tool Templates (SCTT) 2006 Guidelines. See Appendix 1 for a range of resources to assist learning about Service Coordination practice and implementation. This guide can be applied beyond community health to other program areas such as HARP Chronic Disease Management, sub-acute and acute, dental, disability, mental health and drug and alcohol services. Use by any organisation type is welcomed.

6 Part 1 Part 1 Introduction Introduction

7 Service Access Models: A Way Forward Resource Guide for Community Health Services 4 1. Introduction 1.1 Service Coordination Service Coordination places consumers at the centre of service delivery to ensure that they have access to the services they need, opportunities for early intervention and health promotion, and improved health and care outcomes. The fundamental principles that underpin Service Coordination are: a focus on consumers partnerships and collaboration the social model of health competent staff a duty of care protection of consumer information engagement of other sectors consistency in practice standards promotion of an understanding of health as encompassing physical, social and emotional wellbeing. 1 All Community Health Services (CHSs) are expected to embrace the Service Coordination philosophy of consumer care. The process to achieve Service Coordination is as important as the outcome and needs to be incremental, flexible and responsive to local circumstances. Service Coordination models that reflect local circumstances, consumer and community characteristics and service availability have been developed by Primary Care Partnerships (PCPs) and implemented within individual organisations. These models build on existing good practice to develop broader sustainable and systematic practice across Victoria. The Victorian Service Coordination Practice Manual and Continuous Improvement Framework 2 aims to bring together common key features to provide a consistent statewide set of agreed organisational practices, processes and standards. Victoria s Service Coordination model is shown in Diagram 1.1. It depicts the components (or elements) of Service Coordination as identified in the Better Access to Services (BATS) framework 3 and the resources that have been developed to support their implementation. Some elements are more likely to happen in sequence, such as initial contact usually precedes initial needs identification. Others such as exiting service provision, information provision and feedback may happen at any time during the interaction with the consumer, depending on their need. Similarly, how the elements are delivered may differ across settings. For example, in some organisations initial needs identification is carried out by a different person (such as a Service Access or Intake or worker) at a different time to assessment (for example, physiotherapist). In other organisations the same person undertakes initial needs identification and assessment at the same time. The delineation between these 1 Department of Human Services 2001, Better Access to Services: a policy and operational framework. Aged, Community and Mental Health Division, Victorian Government Department of Human Services, Melbourne 2 To be released late Department of Human Services 2001, op. cit.

8 Service Access Models: A Way Forward Resource Guide for Community Health Services 5 approaches is critical to the issues explored in this resource guide and will be discussed further in Part 3. Diagram 1.1 Service Coordination elements and supporting resources For more detail about Service Coordination, please refer to Appendix 1 and the Victorian Service Coordination Practice Manual. 1.2 Service access Service access models (often known as intake systems) support Service Coordination within CHSs. An integrated system supported by systematic processes and consistent practice can significantly contribute to positive consumer, organisational and wider service system impacts. Since the release of the Better Access to Services (BATS) framework, most CHSs have embraced Service Coordination and incrementally implemented it for all or core programs using the Service Coordination Tool Templates (SCTTs). While effort has focused on introducing the SCTTs and aspects of local practices, processes, protocols and systems (PPPS), organisations need to regularly review, and possibly redevelop, systems to ensure that consumers receive consistent support to navigate their way through the service system and obtain timely and appropriate access to services. The term service access models describes approaches that provide systematic, consumer needs identification and access to services, not limited to intake into a single organisation s services As stand-alone, community-managed CHSs and those integrated within rural and metropolitan health services are all required to embed Service Coordination into core business, there are gains to be made if acute and subacute departments adopt Service Coordination principles and processes in line with the community health sector. 1.3 Service access terminology Language influences the understanding and application of Service Coordination concepts. There is much confusion regarding service access language 4 e.g. duty work, intake, Service Coordination, information, intake and referral and intake access are used by various CHSs to describe initial contact and initial needs identification activities. Analysis of organisation experience reveals that these terms actually represent an inconsistent array of functions or tasks. Analysis of organisation experience reveals that these terms actually represent an inconsistent array of functionality or tasks 4 Analysis of the Impacts of Service Coordination on Service Capacity in the Primary Health Care Sector, Final Report (2004). KPMG for Victorian Department of Human Services.

9 Service Access Models: A Way Forward Resource Guide for Community Health Services 6 For an overview of service access functions, see Table 2.2 Service access model functions. For further discussion, see Part 3 for Role and scope of model. In this document the following terms are used: service access models describes approaches that provide systematic consumer needs identification and access to services, including but not limited to intake into a single organisation s services service access system refers to the organisational structures and arrangements that support operation of a service access model service access work - refers to the associated functions or activities that are undertaken to support consumer needs identification and access to services. Intake - refers to the discrete component of service access work that relates specifically to acceptance by an organisation of a request for service and arranging of service provision within that organisation. It is not used to refer to broad variety of front-end Service Coordination activities Common service access language is still developing. Organisations are invited to explore how well service access reflects the role and functions that such systems can provide. The sector may also consider whether global application of the term service access helps strengthen the profile of the service access role and associated functions - internally, externally and across the Victorian community. Definitions of other common terms can be found in the Glossary. Traditional terms to represent a variety of functions and varied interpretations of BATS language continue to highlight the complexity and communication challenges 1.4 Context Policy Current policy at the state, federal and international level highlights the importance of Service Coordination. Quality Service Coordination within community health supports consumer care, pathways between services and within the wider service system, and streamlined organisation systems (see Diagram 1.2). Agencies adopting comprehensive, effective Service Access systems highlight that supporting consumer navigation through the health system is a primary function The Better Access to Services Strategy is: the core driver of reforms in the primary care sector, aiming to achieve a cohesive and coordinated system that promotes seamless and integrated service responses for consumers. This commitment is affirmed in other key health industry policies, including the Community Health Services - creating a healthier Victoria policy, Hospital Demand Management Strategy, Improving the care of older people policy, New directions for mental health services and, most recently, Care in your community a planning framework for integrated ambulatory health care. The vision and intent of several other Government initiatives provide a specific rationale for endeavours to establish a more streamlined and coordinated service access model for consumers, as part of a comprehensive approach to improving Service Coordination 5. 5 Outer East Health and Community Support Alliance 2006, Developing a common 1300 telephone number service access system in the Outer East draft scoping paper, unpublished.

10 Service Access Models: A Way Forward Resource Guide for Community Health Services 7 Appendix 2 explores policies from a Service Coordination perspective and provides links to key policy documents. Care in your community 6 outlines an approach to planning for the health care needs of local communities based on defined geographic areas. It emphasises the significance of well-developed Service Coordination practice and the importance of a planned approach to developing the systems and infrastructure necessary to improve service access and support the delivery of integrated health care to consumers. The following three of the four Care in your community policy principles point to the role that Service Coordination will increasingly play. Principle two: Together we do better Principle three: Technology to benefit people Principle four: A better health care experience The provision of health care will be based on partnerships among levels of government and public and private health care services. There will be a consistent, planned approach to developing the infrastructure for the delivery of integrated health care, including information and communications technology, standard tools and protocols. Care will be person and family centred, focusing on the needs of the whole person as these change over time Information about people and the services they receive will be consistently managed and coordinated across health care services to protect privacy and support integrated service delivery and continuity of care. Good Service Coordination practice provides the building blocks for strengthening community health practices and has informed recent program developments, including the demand management review and the Early Intervention in Chronic Disease in Community Health Services initiative, as well as the development of the Home and Community Care (HACC) Assessment Framework. 1.5 System context To embed Service Coordination, organisations need to review internal systems (addressing how clients move into and within their organisation) and external service systems (such as examining who are key referral partners and the effectiveness of referral pathways to and from those services). Many CHSs have reviewed internal structures, processes, policies and procedures that support how consumer needs are identified and responded to, and have introduced an improved service access system. These organisations regularly review their service access systems and Service Coordination practices as part of continuous improvement cycles, and many are now seeking support with evaluation methodologies. Others are either beginning or part way through an initial review of current practice and subsequent selection and implementation of a service access model. Organisations that have successfully implemented Service Coordination understand that using the tool templates is one part of Service Coordination, but examining and modifying current practice is equally important. In fact, full implementation of Service Coordination requires major revision of client intake processes, including eligibility and risk assessment criteria, an examination of referral mechanisms and a systematic approach to the management of waiting lists. 7 6 State Government of Victoria 2006, Care in your community, a planning framework for integrated ambulatory health care, Victorian Department of Human Services, Melbourne 7 State Government of Victoria 2004, Making it work improving access to services for clients in community health, Primary and Community Health Branch, Victorian Department of Human Services, Melbourne

11 Service Access Models: A Way Forward Resource Guide for Community Health Services 8 Implementing an integrated service access model provides an opportunity to think and act strategically Service Coordination has a wide sphere of influence beyond consumer navigation and access to services, as Diagram 1.2 depicts. How organisations embed Service Coordination also impacts on relationships with partner organisations, functional integration 8 and policy implementation. This creates opportunities to influence the service system as a whole by moving towards greater functional integration and improving consumer outcomes. Diagram 1.2: Service Coordination spheres of influence 1.6 Consumer experience The need to improve consumers experiences within the service system is a major driver for Service Coordination implementation. The 2005 evaluation of the PCP strategy 9 reports mid to high range consumer satisfaction levels with interactions with professionals, information sharing between organisations and receipt of service information and consumer information. The evaluation also indicated that where Service Coordination was implemented more thoroughly, consumers reported more positive experiences. However, qualitative information highlights that much remains to be done to support consumers to determine their precise needs and navigate the broad service system. According to a recent Outer East Health and Community Support Alliance report 10, a sample of consumers surveyed about their experiences with a variety of service access models revealed that: they generally find the service system complex, fragmented, confusing and frustrating to navigate. There continues to be multiple entry points that are not necessarily connected and which offer little consistency in terms of the way they respond. If consumers access the system at one point but need a different service, a successful outcome is more likely to be dependent on the person rather than guaranteed by the system. 8 A form of integration in which agencies and services continue to operate as independent entities but agree to agree to work in a cohesive and coordinated way to ensure that consumers experience a seamless and integrated response. 9 Australian Institute for Primary Care 2005, An evaluation of the Primary Care Partnership Strategy, La Trobe University, Victoria 10 Outer East Health and Community Support Alliance 2006, Developing a common 1300 telephone number service access system in the outer east, draft scoping paper,

12 Service Access Models: A Way Forward Resource Guide for Community Health Services 9 Consumer experience with the service system can differ, with some missing out on services altogether. The report revealed the following issues that a number of consumers face: They don t necessarily know or understand what their issues or needs actually are, and are seeking assistance to help sort through and make sense of their circumstances They don t know who or where to ring When they do begin the phone hunt for a responsive and appropriate service, they are often given a list of phone numbers for other organisations There is often a feeling that these lists are merely options to try, rather than being given with any real knowledge or conviction that they are the right or best option In many instances, they may have to wait several days just to receive a return call Agency after agency will tell them that they don t meet the eligibility criteria, that they are a low priority or that the waiting lists are extremely long or closed By this stage they often give up, or their situation escalates to the point of traumatic or even tragic consequences. Despite this, many consumers believe their service experience is better today than in the past, however this depends to some extent on luck or greater capacity to navigate the system. Those with greater knowledge of the system, or who happen to stumble on the right place to call in the early stages of their distress, often report a positive experience, characterised by timely and responsive service and appropriate support and assistance. Feedback suggests that this is most evident in organisations or sectors where the necessary skills, capacity and resources are available to support uptake of the Service Coordination principles and practices. Consumers have identified several features that depict good practice in service access and intake: Clearly identifiable entry points and processes Timely and responsive service Facilitated referrals and/or assistance with navigating and negotiating the service system Provision of short-term support or interim strategies to help contain issues whilst waiting for ongoing assessment or service delivery Practices that reduce the need to repeat stories, but which adhere to high standards regarding privacy, confidentiality and consent An example where this results in positive consumer outcomes is at Whitehorse CHS. The service access system provides a single point of entry for all allied health services and has led to significantly improved client satisfaction. In an evaluation conducted in 2004, Whitehorse CHS found that 100% of consumers reported being satisfied with the service access process i.e. needs identification, the provision of information and service navigation assistance. This included consumers not eligible for services at Whitehorse CHS. 11 Universal implementation of integrated service access models that incorporate these consumer-identified good practice features could significantly improve the consumer experience Given this information, universal implementation of systematic service access models that incorporate these consumer-identified good practice features could significantly improve the consumer experience. 11 For further details, see the Analysis of the Impacts of Service Coordination on Service Capacity in the Primary Health Care Sector, Final Report (2004). KPMG for Victorian Department of Human Services

13 Part 2 Service access models Part 2 Service access models

14 Service Access Models: A Way Forward Resource Guide for Community Health Services Service access models 2.1 Methodology for identifying the models The classification and articulation of service access models in this guide has been informed by several processes and builds on the three Service Coordination models within the broader primary care sector, as identified in the Analysis of the impacts of Service Coordination on service capacity in the primary health care sector 12. The classification and description of models attempts to integrate learnings from experience to date and provide guidance for the future. These models have been clarified and refined in response to reviews of literature and implementation experience across the community health sector. A series of consultative interviews was conducted with several CHSs to identify their service access models and the methodology used to review, select and implement models. Further information was gathered from the broad knowledge base of many other organisations and PCPs. The diversity of service access models that operate within CHSs reflects variables in structural design, function and resourcing, as well as the complexity and range of funding lines and program mix that the sector supports. This diversity also represents the transitional nature of Service Coordination implementation, for example, some organisations focus on implementing agreed local or regional PPPS and implementing the SCTTs, while others have reviewed and redeveloped internal systems at different rates. Many organisations have prioritised reconfiguration of their service access systems to improve the consumer experience, help strengthen the organisation s strategic position and align with recent State Government and Commonwealth Government policy directions. Leading organisation experience of selecting and introducing integrated service access models has been an organic exercise that each organisation has undertaken in its own way, some with PCP and/or consultancy assistance and others without. This has occurred in the absence of any formal benchmarking, model development, implementation or evaluation guidance. Despite the absence of formal, technical review or evaluation, the models are based on this considerable practice wisdom accumulated over recent years The classification and description of models is intended to reflect the complexity of the environment without over-simplifying the options. It also attempts to integrate learnings from experience and provide guidance for the future. 2.2 Core components of the models A useful way to describe service access models is to consider their three core components structure, function and resourcing. These components are essential, inter-related elements that combine to form an individual service access model. While the components can be addressed in a variety of ways, each should be considered in relation to how they can best achieve the desired outcome in combination with the other two (see Diagram 2.1). 12 KPMG 2005, Analysis of the impacts of Service Coordination on service capacity in the primary health care sector, Final report, Victorian Department of Human Services, Melbourne.

15 Service Access Models: A Way Forward Resource Guide for Community Health Services 11 Diagram 2.1 Core components of service access models 2.3 Structure Structure is the core component of a service access model. It refers to the organisational arrangements and consistency of practices, processes and tools within the service access model. Importantly, structure provides a foundation upon which function and resourcing such as staffing arrangements can be built according to individual organisation requirements. While there are a myriad of structures for service access models, we identify and explore two major types for CHSs, with the primary model incorporating two variations: INTEGRATED SINGLE ACCESS SYSTEM A service access model with a single discrete access point, characterised by systematic and consistent practice for all programs/services. PARALLEL ACCESS SYSTEM A service access model with a combination of discrete access point(s) for most services/programs (organisation/site/ LGA/region based) and additional, discrete program/specialist/ service-specific access point(s). Characterised by integrating mechanisms that support systematic and (mostly) consistent practice for all programs/services. AND NON-INTEGRATED A service access approach with multiple access points, characterised by variable, inconsistent practice per practitioner, discipline, program or site. Coupled with a limited focus on facilitating intake into (or exclusion from) one particular organisation s services, this historically dominant model presents challenges in the current policy environment and direction for seamless consumer care. In addition to the models described here, examples of hypothetical structural designs and descriptors can be found in Appendix 3. While the descriptions used do not precisely match those above, they have been included to facilitate preliminary thinking about hypothetical options and to provide a brief commentary about benefits and disadvantages at a conceptual level.

16 Service Access Models: A Way Forward Resource Guide for Community Health Services Function Service access systems can perform a range of functions on behalf of consumers, organisations, services and the wider service system. An integrated system provides the potential to centralise and systematize other activities such as the implementation of quality improvement activities, health promotion initiatives and distribution of emergency relief/material aid. Service access work essentially involves undertaking the IC and INI elements of Victoria s Service Coordination model. Service-specific or specialist assessment and care planning are separate functions, although they may occur on the same occasion or be undertaken by the same practitioner, and care planning may commence when a consumer first makes contact with the service access system. As noted, analysis of organisation experience to date reveals little consistency with the current system response to consumer and referrer requests, involving an array of functions or tasks undertaken in a myriad of combinations, at different points along the consumer journey, on an ad-hoc basis or not at all. As most of these functions have traditionally been undertaken as aspects of assessment or intake into one particular organisation or service, distinguishing them as components of, or associated with, INI continues to present a challenge to the sector. As organisation implementation of Service Coordination varies, INI can occur along with IC and/or service-specific, comprehensive or specialist assessment, or as a discrete activity. While service-specific access is highly desirable and necessary for consumers to receive services and meet internal organisation requirements, managers should consider how processes allow for broad screening/ini to occur in addition to and discrete from service-specific assessment. In organisations where discrete service access units are in place, the distinction between these Service Coordination elements is usually clearly defined. Service access systems can perform a diverse range of functions on behalf of consumers, organisation services and the wider service system However, where INI is built into the first assessment appointment it can be difficult to ensure that the consumer s broad needs are identified and explored holistically, because service-specific requirements may dominate. Organisations report that it is difficult to monitor or determine how effectively this combined process works, or if INI beyond the presenting problem does, in fact, consistently occur. While some core access functions are common to all CHSs, other functions that have long been undertaken by CHSs can now be incorporated into consistent service access work. Organisations should consider centralising these functions and determining the most appropriate point to provide them - within the consumer journey and to best suit internal structures, workflow and business processes. For a systematic service access system to operate effectively, functions must be clearly identified, described and documented within policies and guidelines. They must be understood by all staff and, most importantly, be consistently provided and monitored. This is explored in Part 4 and examples of policies and guidelines are provided in the accompanying Toolkit. The historically dominant approach to service access relies on reception staff and individual practitioners or disciplines to duplicate a complex set of activities to determine need, eligibility and access to their service only. This approach presents challenges in the current policy environment of aiming for seamless consumer care. Establishing an integrated service access model provides the service system with the means to respond more holistically to consumers, particularly those with complex or chronic needs. It also provides the opportunity to provide services early in a consumer s journey, beyond simply identifying a presenting need, eligibility screening and providing information. See Table 2.2: Service access model functions and further discussion in Part 4 Determining which services and functions are in scope.

17 Service Access Models: A Way Forward Resource Guide for Community Health Services Resourcing Financial Reallocation of organisation resources is usually required to successfully establish and maintain an integrated access model. While this can pose initial challenges, many organisations have effectively reallocated resources as part of the overall change management process. This process relies heavily on first identifying the percentage of service delivery time that is used (and wasted) duplicating service access functions across the organisation. This data can then be used to support reallocation of the equivalent value from services that will be supported by the new system. The allocated funding can then be used for staffing and infrastructure costs. While the reallocation process can have variable initial impacts on demand management and staff attitudes, once the model is functioning efficiently, the overall improved efficiencies, the increase in practitioner time for service delivery, and improved quality of service for the consumer are highly valued Infrastructure Infrastructure resources to support service access systems can include: office accommodation telephony, such as phone systems and headsets IT requirements, such as hardware and support administrative costs, for example, records management, information resources and postage Staffing Four staffing options can support service access models: dedicated rostered allocated activity individual role activity. Staffing by individual role activity has been the dominant approach; however, this can result in duplication, inconsistent practice, inefficient use of resources and nonuniform responses to consumer needs. Once the model is functioning efficiently, the overall improved efficiencies, the increase in practitioner time for service delivery, and improved quality of service for the consumer are highly valued Factors influencing selection of a staffing option may include staff preferences or availability of suitable staff; however, it is recommended that organisations consider this primarily from a strategic and operational perspective, following the selection of a suitable model. See Table 2.3 Overview of staffing options, and the Staffing options comparative chart in Appendix 5 to compare the features of each option. Staffing resources to support service access systems can include: project leader or ongoing service access coordinator role - equally important with both dedicated and rotating staffing options dedicated practitioner and/or administrative positions - if implementing dedicated staffing option training costs for example, program eligibility criteria & screening requirements, suicide intervention, e-referral supporting administrative roles backfill positions - if implementing dedicated staffing option. Most organisations report that the most suitable staffing option incorporates a mix of both practitioner and administrative positions.

18 Service Access Models: A Way Forward Resource Guide for Community Health Services Identified service access models While the identified service access models for community health of Integrated: Single Access System or Parallel Access System and Non-Integrated models are classified in terms of structural design, they are also defined by practice characteristics (See Table 2.1: Overview of service access models). Consistency in practice according to common guidelines is the core feature of integrated models. Each model can support a variety of functions and incorporate a range of staffing options, as described in Tables 2.2 and 2.3. Each model is also applicable irrespective of the number of organisation sites. While identifying variations to the models does not preclude further variations, organisations should aim to establish as simple yet robust a model as suits their operating environment and strategic position within the service system. The Non- Integrated model represents the historically dominant practitioner/discipline-specific model, which is unlikely to effectively meet present day demands. Comparisons of features associated with each model can be examined in the Service access models comparative chart in Appendix 4. As depicted in Diagram 2.2, the models can also be described as points along a continuum which culminates in achieving a truly integrated service access model. For example, many CHSs have adopted a form of the Integrated, Parallel Access system which does not yet incorporate common procedures, while others are using a combination of the Non-Integrated system and program/specialist/service-specific access points, while extending the scope incrementally and working towards using consistent practice. Often the biggest challenge of this transitional process is ensuring that integrating mechanisms which support systematic and consistent practice for all programs/services are built in. Often the biggest challenge of this transitional process is ensuring that integrating mechanisms which support systematic and consistent practice for all programs/services are built in. Diagram 2.2 Continuum toward an integrated service access model

19 Service Access Models: A Way Forward Resource Guide for Community Health Services 15 Table 2.1 Overview of service access models Model Access Description Example Integrated Single Access system A single discrete access point, characterised by systematic and consistent practice for all programs/services A service access unit consistently undertakes all core and some additional service access functions on behalf of all organisation services that are delivered across multiple sites (for example, allied health, counselling, Planned Activity Group, alcohol and drug and dental clinic), in accordance with agreed practices and procedures Parallel Access system A combination of discrete access point(s) for most services/programs (organisation/site/local government area/region based) and: additional, discrete program/specialist/servicespecific access point(s) characterised by integrating mechanisms that support systematic and (mostly) consistent practice for all programs/services A service access unit consistently undertakes all core and some additional service access functions on behalf of allied health, counselling and Planned Activity Group services, and: a medical access point provides broad INI as well as intake for the GP clinic supported by a common set of practices and procedures and appropriate mechanisms for providing integrated care across the organisation. Non - Integrated Multiple Access Points Multiple access points characterised by variable, inconsistent practice per practitioner/discipline/ program/site. Each practitioner responds to enquiries, screens, makes appointments and manages a waiting list in an individual or discipline-specific manner. Historically dominant model presents challenges in the current policy environment and direction for seamless consumer care

20 Service Access Models: A Way Forward Resource Guide for Community Health Services 16 Table 2.2 Service access model functions Functions Core Identifying presenting need Assisting with sorting through circumstances and exploring broader needs Eligibility screening Risk screening Determining priority Facilitating consumer navigation of the service system Providing service and/or consumer information Offering and providing assisted referrals 13 Identifying health promotion opportunities Providing short-term support or interim care strategies Undertaking intake procedures into organisation services Facilitating access to assessment and/or care planning Additional Appointment scheduling Undertaking demand and waiting list management Educating consumers regarding service system initiatives, for example: o Medicare Benefits Scheme Enhanced Primary Care or Mental Health Care initiatives - access to private allied health, psychological or psychiatric services o Nurse-On-Call etc Undertaking needle and syringe exchanges Providing material aid Facilitating care planning, for example: o o Other identifying suitable consumers and relevant service providers establishing initial meetings 13 Assisted referrals: When practitioners within the service system make a referral on behalf of a consumer. Primary Care Partnerships, Victorian Service Coordination Practice Manual (unpublished draft, Nov 2006). Effective Change, HDG Consulting

21 Service Access Models: A Way Forward Resource Guide for Community Health Services 17 Table 2.3 Overview of staffing options to support models DESCRIPTION COMPOSITION SKILL BASE Dedicated Staff specifically allocated to undertake service access activity on behalf of the organisation, as their primary role. Incorporates a global approach to consumer needs identification. Rostered Staff rostered to undertake service access role on behalf of organisation for specific timeframes, in addition to their normal service delivery role. Incorporates a global approach to consumer needs identification. Allocated Activity Staff within a discipline/ service/program/team undertake service access activity on behalf of that team, as a permanent component of their role. Primary focus is on intake processes. E.g. Allied Health Assistant responds to access queries on behalf of Allied Health Team or Chronic Disease Self Management Program. Individual role activity Discrete teams/individual From any discipline, service or program Discipline/team service/program/ specific Individual/role specific Qualified health/welfare professional (practitioners), generally with significant experience Non practitioner usually highly skilled and trained and backed up with decision support tools and practitioner support Qualified practitioner Non practitioner usually highly skilled and trained (eg. AHA), with decision support tools and practitioner back up Qualified practitioner Qualified practitioner Individual staff undertake service access activity for their discipline/role only, as a permanent component of their role. Primary focus is on intake processes. Historically dominant staffing approach inefficient & inconsistent

22 Service Access Models: A Way Forward Resource Guide for Community Health Services Service access models: a way forward Part 3 looks of this resource guide at the principles of model selection. It will become clear from reading those principles that to achieve optimal system and consumer outcomes within individual organisation limitations, the Integrated model options provide the most effective way forward. The historically dominant Non-Integrated model presents challenges in the current policy environment and direction for seamless consumer care. It no longer equips organisations to adequately meet service access requirements. Universal factors, such as the growing complexity of the service system, increased demand for services, and consumer and referrer expectations, indicate that a more integrated approach is now warranted. To achieve optimal system and consumer outcomes within individual organisation limitations, the Integrated service access model options provide the most effective approaches.

23 Part 3 Principles for model selection Part 3 Principles for model selection

24 Service Access Models: A Way Forward Resource Guide for Community Health Services Principles for model selection 3.1 Factors driving change and influencing model selection There are many factors for CHS managers to consider when contemplating how to further embed Service Coordination. The change management involved requires sustained leadership, commitment, resourcing and effort to achieve substantive system improvements, operational efficiencies and the strategic goal of enabling better access to services for consumers. An important foundation is to start with the end in mind and ensure that structure follows strategy Selecting, reviewing and configuring a service access model requires strategic consideration of the factors driving change and influencing model choices. These include: strategic positioning in line with policy directions management structure and responsibilities reorientation away from organisation-centred focus to consumer focus duty of care embedding of PPPS across organisation practice quality of service and continuous improvement quality evaluation and review processes the need to use resources effectively and efficiently the need to increase business efficiencies by embedding functional, efficient organisation Service Coordination models that streamline processes and reduce/eliminate duplication of effort demand and waiting list management catchment demographics program mix geographical/site factors regional collaboration and cooperation relationships and arrangements with referral partners preparation for and implementation of electronic referral (ereferral). Management factors strongly influence model selection and operation. Program mix within each CHS also plays a role. For a service access model to provide effective consumer outcomes, it must be supported by management arrangements that align with and progress organisation and service system priorities, including strategic and operational goals, program, team and site objectives, and quality objectives. Organisation managers with responsibility for service access systems are effectively agents of change, and as such, require organisation-wide and broader support to fully embed these changes.

25 Service Access Models: A Way Forward Resource Guide for Community Health Services Desirable Service Coordination outcomes The selection and adoption of a service access model should be based on demonstrable outcomes that maximise consumer outcomes, organisational and operational effectiveness and efficiency, and progress integration of the service system. Selection should consider how a model achieves the following factors: consumer-focused care care planning effective service system improvements organisational alignment viability and sustainability quality and clinical support demand management risk management. Organisation managers are encouraged to consider the following breakdown of these factors to determine if a proposed model meets Service Coordination objectives Consumer-focused care Supports consumer-focused care vs. service provider/practitioner focus of care. Is responsive to: consumer social, psychological, medical and physical aspects as appropriate cultural requirements, language and special communication needs Demonstrates benefits to consumers: provides ease of access to services for consumers/service providers supports consumer navigation through the system and assisted referrals provides faster response to consumers seeking services provides for early identification of broad consumer needs (including beyond presenting issue where relevant) supports coordinated consumer care &and promotes continuity of care, especially for those with complex needs or multiple service requirements improves capacity to identify and respond to emergency/crisis situations and manage immediate risks. Increases ability to provide consumers with consistent up-to-date services information. Supports consistent application of consumer privacy and consent principles. Maximises opportunities to provide brief interventions at or soon after INI. Maximises health promotion opportunities Care planning Supports appropriate eligibility screening and early intervention for targeted consumer groups Can provide targeted intake function for specific disciplines/programs/consumer groups Enhances coordination of care for consumers requiring multiple services Supports streamlined, quality consumer information sharing and referral (internal & external) Provides clear & simple referral point for GPs & other referrers

26 Service Access Models: A Way Forward Resource Guide for Community Health Services 21 Enhances ease of electronic referral deployment and central incoming referral point Promotes continuity of care Effective service system improvements Reflects the BATS strategy, which promotes: a central focus on consumers partnerships and collaboration primacy of duty of care social model of health competent staff protection of consumer information engagement of other sectors building practitioner capacity and understanding of the broader service system consistency in practice standards promotion to practitioners and consumers of an understanding of health as a complete state of physical, social and emotional wellbeing builds stronger relationships and appropriate information flow between referral partners (internal and external): enhances interfaces between acute, sub acute and primary care sectors enables integration internally and externally encourages greater capacity for collaboration and cooperation Organisational alignment Supports alignment between policy direction, organisational strategic goals and Service Coordination objectives, Enhances shared organisational vision, leadership and sustained capacity for change, Supports embedding of organisational structures, policies and procedures that advance Service Coordination objectives. Raises the community health sector profile and the holistic, less clinical focus to meeting consumer needs. Is supported by a comprehensive change management strategy and leadership. Improves business practice and drives cultural change while building on strengths. Increases/maximises efficiencies: reduces duplication/duplicated effort streamlines/improves internal practices provides for more effective use of resources. Clearly delineates role/task breakdown to support streamlining of organisational requirements, for example, appointment scheduling and waiting list management Quality and clinical support Encourages and supports good/best Service Coordination practice and clarifies role of all staff. Meets Victorian Service Coordination Practice Manual and Continuous Improvement Framework standards. Supports effective care planning

27 Service Access Models: A Way Forward Resource Guide for Community Health Services 22 Incorporates quality measures/benchmarking to support continuous improvement, embedding of local and statewide PPPS, quality assurance reviews and meeting of accreditation standards. Incorporates appropriate clinical governance and support, for example: service guides risk assessment and prioritisation categories and tools other decision support tools and protocols Incorporates good client information management and data collection systems and practices that: track consumer journey and service use allow for easy measurement of demand, organisation response, unmet need and service gaps record and emphasise the value of IC and INI support recall systems produce meaningful reports which inform service planning and resource allocation. Aligns with HealthSMART patient/client information management systems functionality Maximises potential for quantitative outcomes, including: increased capacity for direct service delivery due to less administrative demands on practitioners reduced number of service sessions for some consumers due to less administrative requirements during service delivery time reductions in double processing of data and associated reduction in hours required to process documentation. Monitors workload of staff resourcing service access system Viability and sustainability Supports organisation implementation of policy directions around clear points of access, consumer-centred care, broad and consistent needs identification, information sharing, managing consumers with chronic and complex needs, facilitating continuity of care and integrated care. Maximises embedding of Service Coordination across the organisation and use of tools such as SCTT, ereferral, electronic service directories. Addresses demand factors, supply factors (for example, efficient use of service delivery time), cost-effectiveness, resourcing, evaluation and continuous improvement. Is supported by an appropriate resourcing model for infrastructure and staffing that is linked and can respond to changes or growth in program mix, and provides continuous coverage and satisfactory response time. Provides appropriate support and debriefing for service access staff (dedicated staffing option). Is supported by appropriate infrastructure, such as accommodation, IT, telecommunications, records management. Increases capacity to identify unmet need and advocate for or allocate appropriate resources Demand management Supports consumer navigation through the service system and the provision of assisted referrals to obtain required services. Supports easy measurement of demand and unmet need.

28 Service Access Models: A Way Forward Resource Guide for Community Health Services 23 Supports development and application of consistent demand management policies and practices. Enhances management of increasing demand for services while balancing the organisation s capacity and client needs. Allows for development and application of consistent target strategies to ensure equitable demand management. Enhances consistent waiting list definition, categorisation and management. Supports development and implementation of early intervention strategies that: allow for intervention/ to commence while waiting for assessment/services reduce consumer duplication on waiting lists reduce waiting list times and numbers improve consumer outcomes Risk management 14 Operates with fully documented service access policies, practices and guidelines. Supports development of clearly articulated performance indicators, including policies dealing with breaches in protocols and practice. Distinguishes between INI and Service specific assessment Allows for clear identification of potential risks to consumers Allows for clear identification of potential risks to organisation Provides for clearly articulated risk management or treatment strategies that address clinical and non-clinical (program functions) factors and occupational health and safety (OH&S) factors (such as crisis or critical incident management). Ensures appropriate identification and resolution to practice issues, guided by practitioners clinical and professional expertise, organisation policies and best practice (or current standard) Provides for well defined, evidence based risk identification and prioritisation tools that are appropriate and available for identifying the clinical and psychosocial factors for a range of needs, disciplines and services Maximises use of control measures processes, policy or actions that minimise negative risk or enhance positive opportunities, for example, guidelines for risk assessment and priority screening tools. Addresses additional risk factors relating to: information management - IT and communications systems, client records security management internal and external emergencies. Ensures appropriate consumer complaints/feedback mechanisms around service access and response. Ensures periodic review, understanding and adherence to control measures, for example, management of crisis presentations. Adopting a service access model with these features will provide a CHS with the capacity to comprehensively embed Service Coordination across the organisation. 14 Acknowledgment to Standards Australia (2004), Australian and New Zealand Standard, Risk Management AS/NZS 4360:2004, Council of Standards Australia.

29 Service Access Models: A Way Forward Resource Guide for Community Health Services Review of current system or models All CHSs currently provide some sort of response to consumer and service provider enquiries. When considering how to implement an Integrated service access model or improve an established one, it is critical to review the current approach and activity. It is expected that organisations will find commonalities with and distinctions between models described in this guide and those currently in place. A review is a valuable continuous improvement activity that will inform how well the organisation is providing the front end of Service Coordination and, most importantly, identify what further consumer, organisation and system improvements can be achieved through implementing an alternative model or improving a current model. The following activities are recommended: Assess the consumer experience - identify the number of multiple ways a consumer currently enters your services and the pathways they have to navigate Determine the time currently spent on IC, INI and referral across the organisation and identify duplication or inefficiencies Review current systems and processes against the desirable Service Coordination outcomes outlined above and the Victorian Service Coordination Practice and Continuous Improvement Framework Identify which functions are performed at what point, and which could be integrated Review current practice against the Service access models comparative chart in Appendix 4 Identify strengths and gaps of current practice with respect to the comparative chart Consider how the organisation might best deliver the desirable outcomes in the future In order to determine the most appropriate model for each set of circumstances, it is also important to find points of commonality 15 across the sometimes diverse program mix within an organisation, which could form the foundation of common approaches. The points listed below may provide a useful starting point: There may be a number of separate intake functions with close relationships and similar processes; Referrals may be able to be grouped according to referral sources (eg: from service providers, consumers) Some disciplines/teams may have developed tools or protocols to assist with screening for eligibility and urgency that could be adapted for more universal use. Once staff become accustomed to the use of protocols, new protocols can be introduced more readily; HARP Chronic Disease Management programs are required to use a defined point of access that may be incorporated within the CHS; and Most services use the same or compatible software platforms e.g. SWITCH, which can support Service Access functions. Another approach to improving efficiency and quality of service is called lean thinking. This process improvement methodology has been taken up across the manufacturing and other industries with staggering improvements in quality and efficiency 16. Recent application of lean principles to health care in Australia and the UK has sparked considerable interest and resulted in significant improvements in efficiencies, patient flow, safety and satisfaction. 15 Adapted from Southern Health, Defined Points of Access project draft Concepts Paper. Prepared by Dr Ro Saxon, HDG Consulting Group, July Nigel Edwards, Policy Director, NHS Federation, UK National Health Service

30 Service Access Models: A Way Forward Resource Guide for Community Health Services 25 Lean thinking principles have been successfully used by Britain s National Health Service 17, Flinders Medical Centre in South Australia and are being applied to the Department of Human Services Patient Flow Collaborative II Outpatients 18, in which four CHSs are participating with their local health service. The industrial improvement strategies of lean thinking are now being translated into healthcare systems. Lean Thinking has five principles, which can be applied to healthcare 19 : 1. The goal is to add value from the consumer s standpoint, not the service provider s standpoint 2. Identify all the steps necessary to add value at every point for every consumer group 3. Make the consumer s journey flow as smoothly as possible 4. Do only what is determined by the consumer s needs and rate of demand 5. Manage towards perfection by continually removing blockages, duplications and wasteful processes as they are identified Practice review tools available in Section 7 of the Toolkit can also assist with determining current practices and potential areas for improvement. 3.4 Supportive organisation features Key organisation features organisational features and operational processes promote and support Service Coordination and integrated service access models Organisational features Board of management or health service executive commitment to broad systems thinking and clear shared vision for embedding Service Coordination. Organisation capacity for sustained change management. Identification of clear Service Coordination change management objectives, activities and outcomes in organisation strategic and business plans. Linking Service Coordination into business practice by embedding PPPS and Service Coordination practice standards into organisation policies and procedures, position descriptions and orientation processes. Comprehensive change management planning and processes identified and implemented, supported by an allocated role and/or other structures to manage the process. Clarity of role, responsibilities and authority of supporting organisation structures, for example, working group/change leaders enabling implementation of changes/continuous improvement measures, with management support. A systematic approach to implementation and review of changes. Commitment to continuous quality improvement, with Service Coordination embedded into policies and practice from a quality perspective, and across all organisation activities. Defined service access model in place with clearly identified access points, common functions, procedures and referral features. 17 See Lean thinking for the NHS (2006), by the Lean Enterprise Academy and commissioned by the NHS Confederation at UK National Health Service (NHS) National Library for Health

31 Service Access Models: A Way Forward Resource Guide for Community Health Services 26 Clearly defined processes for eligibility and priority screening and waiting list management across multiple disciplines/program areas. Commitment to ongoing staff development and training in Service Coordination, for example, widespread use/reference to the Self-Paced Service Coordination Training Module. Strong relationships with referral partners and ongoing development of emerging relationships. Ongoing participation in PCP initiatives (such as Service Coordination committees, projects, practitioners groups) and engagement with service providers across a range of sectors Operational processes Staff understanding of relevance and application of Service Coordination, for example, Self Paced Service Coordination Training Module incorporated in orientation programs and conducted at regular intervals. Full range of Service Coordination elements across all practitioner roles as a matter of course (not just dedicated service access staff), including IC, INI, assessment, care planning and referral. Service access units staffed on a rostered or dedicated basis by qualified health practitioners or skilled non-qualified staff with clear decision structures and practitioner support. Practitioners from different disciplines/program areas working together and supported to implement care planning and referral practices (not just relying on dedicated service access staff to undertake IC, INI and referral). Holistic approach to client care and coordination, including support with navigation through the service system and provision of assisted referrals. Clearly defined eligibility and prioritisation standards and practices for multiple disciplines/services. Incorporation of health promotion/preventative activities within INI processes. Strong relationships with referral partners, underpinned by shared practical understanding of the organisation s limitations and other organisations capacity. Quality information exchange - referral, assessment and feedback crucial for coordination of services. Supported by timely and informed response to client needs; appropriate use of SCTTs, service directories, ereferral; and consistent use of ereferral systems (where available) and other referral mechanisms. Participation in PCP initiatives (for example, practitioners groups, projects) by staff at all levels within the organisation, supported by a clear communication strategy.

32 Service Access Models: A Way Forward Resource Guide for Community Health Services Model consideration The identified models reflect the variety of service access models within the community health sector and beyond. It is recommended that the options are considered in light of an organisation s strategic priorities and positioning. While current access models, staffing and program mix are significant factors, organisations should also consider how to best meet the outcomes listed above. Local demographics and organisation cultural and site aspects, as well as implementation factors related to each model and staffing option should also be considered. Given the many factors to consider, many organisations take a staged approach to introducing services or functions. Diagram 3.1 depicts the complexity of factors to be considered when selecting a service access model. Please see Diagram 2.1 and related text for discussion regarding the central service access model components. Diagram 3.1 Complexity of factors to consider Role and scope of model It is important to consider both the scope of services to be included as well as the scope of functions to be provided by an integrated model. Many organisations find that a phased approach can help embed the system progressively. This involves considering which services or programs to include and which functions the system will undertake on behalf of those services (see Part 4). Features of the models are listed in the Service access models comparative chart and Staffing options chart in Appendix 4 and 5. The charts highlight strengths, challenges, implementation distinctions, viability and sustainability and risks associated with the models and staffing options. Features are comparatively charted according to their perceived impact on consumers, coordination of services, best practice, workforce and organisation or broader systems. While the comparisons are intended to reflect learnings from significant organisation experience, they act as a guide only and, as much is subject to interpretation, individual views may vary. To help guide a selection or review process, organisations

33 Service Access Models: A Way Forward Resource Guide for Community Health Services 28 are encouraged to use the associated workbook in Section 7 of the Toolkit to undertake a similar comparative process at an individual organisation level. The Implementation distinctions section of the Service access models comparative chart outlines some subtle implications, particularly in relation to the Integrated, Parallel Access model. Part 4 of this guide explores implementation factors and supportive change management processes. All decisions should be given careful consideration in context with organisation circumstances. This can be an emotive process. However, while all models involve some risk, maintaining a Non-Integrated model carries inherent risks and perpetuates the status quo. It is important to keep in mind that the selection of a model for your organisation is both a combination of using the good evidence that is available and also making educated guesses about how the model will work in your individual setting. It is about boldly going where others have gone before.

34 Part 4 Implementation Part 4 Implementation

35 Service Access Models: A Way Forward Resource Guide for Community Health Services Implementation 4.1 Learning from experience Until recently, the dominant model of access to CHSs consisted of multiple access points to individual practitioners or disciplines, characterised by inconsistent practice and paper-based processes that varied per practitioner, discipline, program or site. There are now clear imperatives for CHSs to adopt integrated service access models. These include: significant technological and system advances increasing complexity of the service system rising demand for services increasing numbers of consumers with chronic or complex conditions or greater acuity stronger links with the acute and sub-acute sectors Despite significant challenges associated with re-orienting organisation structures, processes, financial and human resources, establishment of an integrated service access model plays an important role in influencing the paradigm shift and systems change required to achieve greater functional integration within the broader service system. This could be considered in terms of think globally act locally. CHSs are in a pivotal position to act as key agents of change in effecting system improvements for consumers. This can be highlighted by demonstrating the difference between facilitating consumer navigation and access to the service system as a whole, as opposed to arranging entry or intake into a single organisation only. This could be considered in terms of think globally act locally, with CHSs being in a pivotal position to act as key agents of change in effecting system improvements There are many common elements for organisations implementing service access models. However, managing the change process is the key element. How this is addressed pervades all other aspects of implementation and is the key to success. There are now clear imperatives for community health services to adopt integrated, centralised service access models Managers may wish to review Making it work improving access to services for clients in community health 20 for examples of how individual organisations have undertaken major revision of client intake processes, including eligibility and risk assessment criteria, an examination of referral methods and a systematic approach to the management of waiting lists. Another useful resource is Better quality, better health care: a safety and quality improvement framework for Victorian health services, published by the Victorian Quality Council. This framework provides a strategic overview of the key principles and practices necessary for effective monitoring, management and improvement of health services. It is built on a foundation of clinical governance, which clearly delineates the board responsibility for ensuring that service and care quality is addressed with the same rigor as financial governance, and that corresponding accountabilities are delegated throughout the organisation. It describes the intersection between four critical organisational processes essential for quality improvement and six dimensions of quality, as well as exploring related roles and responsibilities throughout the health system. The framework is available at: 20 State Government of Victoria 2004, Making it work improving access to services for clients in community health, Department of Human Services, Melbourne

36 Service Access Models: A Way Forward Resource Guide for Community Health Services Change leadership Change is an integral feature of the community health sector. Change management has been recognised as a complex, dynamic process during which unanticipated events and behaviours may emerge. This is particularly the case for community health care organisations where the combination of a number of typical features serves to complicate change efforts. Change in complex organisations such as community health services is unlikely to be a straightforward process and is likely to require more than one approach. 21 This is particularly relevant for integrated CHSs where outside influences and priorities from the acute or sub-acute sectors may also have an influence. Undertaking major change in such an environment can be challenging and exciting, and capacity must be developed to ensure that managers and practitioners are skilled in leading and adapting to ongoing change. Regardless of how changes are viewed, we each react differently when any change strategy is adopted. It is recommended that the emergent change approach driven from the bottom up and as an ongoing process of adaptation to changing circumstances 22 is a suitable model for CHSs to adopt as: change is seen as a learning process that is not linear and sequential, but a continuous process of transition involving continual adjustment of goals, unanticipated events and disruption. Change is driven using a learning change strategy where employees participate and contribute to continuous improvement as part of their everyday work 23. Another important aspect in the selection and implementation of a new service access model is change leadership. Change leadership is multifaceted, comprising corporate and individual aspects; and multi-layered, involving a board of management or executive team, executive officer, management team, team leaders and project leaders. Engaging corporate change leadership is vital to the successful implementation of a service access model. A critical risk factor arises if responsibility for a change management process is left primarily to a specific change leader (for example, project leader, team leader), without visionary and strategic support by the whole of corporate leadership. The change management process needs to be mutually owned. Many individuals can take up a change leader role, either within specific teams or facilitating specific aspects of a wider process. Practitioners and other staff can then be provided with a clear wholeof-organisation model that guides the review, consultation, communication, selection, implementation and evaluation processes. The change leader role can be one of the most challenging and rewarding roles that any manager or team leader will play. It requires the full cooperation and support of corporate leadership and staff. The role 24 of change leadership and that of a change leader is to: facilitate and drive the change process promote Service Coordination and the development of a service access model strategy as a whole-of organisation approach develop and manage the transition strategy contribute to and oversee development of a service access implementation plan undertake the review of current practice with relevant staff 21 Telford, K. Maddox, A. Isam, C and Kralik, D. 2006, Managing change in the context of a community health organisation, Australian Journal of Primary Care, Vol 12, No. 2, August Telford, K. Maddox, A. Isam, C and Kralik, D. op. cit. 23 Telford, K. Maddox, A. Isam, C and Kralik, D. op. cit. 24 Adapted from Banyule Nillumbik Primary Care Alliance 2003, Change Management presentation prepared by Deb Warren.

37 Service Access Models: A Way Forward Resource Guide for Community Health Services 31 guide and monitor delivery of the implementation plan develop and deliver an ongoing communication strategy tailor and deliver service access orientation and promotion within the organisation and the wider service system identify staff orientation requirements and incorporate into workforce development plans contribute to and guide development of policies and procedures manage risks that have been identified, acknowledged and planned for monitor practice to ensure that changes are implemented as agreed and that the change is occurring effectively incorporate ongoing review of the service access system into continuous improvement and quality planning processes and plans facilitate an evaluation process after an agreed time, A useful resource for change leaders is the Victorian Quality Council s Successfully implementing change. This document discusses common issues that arise when introducing change as a component of continuous quality improvement, and outlines strategies that may improve the likelihood of success. It can be accessed at ange.pdf 4.3 Determining the services and functions in scope Considering both the functions and services to be incorporated helps define and shape the rollout of an integrated service access system. Determining the precise role that the system is to play, identifying the programs, services, teams or disciplines and which common functions will be performed is best undertaken as an organisation-wide activity. The distinction between providing intake as opposed to Service Coordination comes into play here. It is very important to highlight that the primary purpose is to meet consumer needs by providing timely access to appropriate services, wherever they may be found within the service system. In addition to providing this broader navigation support role, it is also necessary to undertake the organisation s intake processes within the service access system. Determining which programs or services are to be incorporated can be as simple as deciding to include all. It will then be necessary to decide whether all services should be incorporated at the same time or via a staged approach, which can help embed the system progressively. While it may first appear that certain services or program areas cannot or should not be incorporated, it is important to find points of commonality across the sometimes diverse program mix within an organisation, which could form the foundation of common approaches. For example 25 : there may be a number of separate intake functions with close relationships and similar processes referrals may be able to be grouped according to referral sources (from service providers, consumers) some disciplines/teams may have developed tools or protocols to assist with screening for eligibility and urgency that could be adapted for more universal use (once staff become accustomed to the use of protocols, new protocols can be introduced more readily) 25 Adapted from Southern Health Primary Care Defined Points of Access Project concepts paper (unpublished draft, July 2006). HDG Consulting Group

38 Service Access Models: A Way Forward Resource Guide for Community Health Services 32 Hospital Admission Risk Program Chronic Disease Management (HARP CDM) programs are required to use a defined point of access that may be incorporated within the CHS most services use the same or compatible software platforms, such as SWITCH, which can support service access functions. Common functions and processes can then be integrated to capture service-specific idiosyncrasies, while ensuring consistency for consumers and referrers. Procedures should be clearly documented, reinforced and monitored to enable consistent application. A staged approach Using a staged approach to incorporate services and functions involves considering which services or programs may initially or subsequently be included, as well as which functions the system will ultimately undertake on behalf of those services. For example: Services Stage 1: Stage 2: Stage 3: Functions Stage 1: Stage 2: Allied health services Counselling and early childhood Dental All core service access functions and needle exchange provision Appointment scheduling, waitlist management and material aid provision 4.4 Implementing change: keys for success Although implementation will vary from organisation to organisation, a number of universally applicable keys to success are outlined below. For greater detail on how several CHSs reoriented their business processes to improve service access, also refer to the Making it work improving access to services for clients in community health resource (see Appendix 2). Common keys to success include the following: Visionary leadership to lead organisational change and optimise staff buy in and adoption of a whole-of-organisation approach. A clear understanding of drivers for change and agreed commitment to system redesign as a whole-of-organisation priority. Acknowledging the limitations and inefficiencies of current arrangements, as well as the value of committing time and effort to become consumer-focused and efficient. A clearly articulated aim that is straightforward and uncomplicated. Objectives defined early in the process. Developing key milestones and regularly reviewing progress. Recognising this as a change management process and undertaking to maximise opportunities for change. Acknowledging and supporting change and involving all staff and key stakeholders in managing that change. Clearly articulating change management processes. Convening a project working group with representation from key areas and delegated authority to provide input and feedback.

39 Service Access Models: A Way Forward Resource Guide for Community Health Services 33 Unambiguous decision making at critical points with clearly articulated designated lines of authority and roles. Appointing a dedicated project role or champion to ensure review, selection and implementation processes stay on track. Building and maintaining trust. Visionary leadership - the initial key to organisational Adopting a consultative process with board of change management management/ executive, managers, staff and key stakeholders. Creating a safe environment to facilitate creativity and build capacity - to dare to dream and conceptualise what a future service access system might look like. Early decision making about which services to bring on first, which to leave outside of scope, and which functions to incorporate. A Parallel Access system can be used to accommodate organisational complexity. This can provide improved service access supported by integrated, consistent approaches, but allows for target consumer groups to be addressed independently. Alternatively, adoption of a staged or evolutionary approach can allow for the incorporation of services and functions where across-the-board change is not immediately achievable or desirable. Early consideration of possible resource expenditures and reallocation of resources. This could include impact assessment around financial viability and conducting a risk assessment (and/or a health impact assessment 26 ) of the selected model against all factors affecting clients, the organisation, referral partners, and so on. Strategies may include reallocating a percentage of each service s operating costs, transferring EFT allocation from unfilled positions and/or using growth or rollover funds. Scoping out and factoring in the cost of design and implementation for inclusion in the overall work plan. Recognising that implementation will require potential changes to: staffing profiles roles and responsibilities work practices policies and procedures physical infrastructure IM/IT and telecommunications. Developing a communication and education strategy that includes internal and external stakeholders - clients, the community, other service providers, internal services, staff. This includes open and regular communication between board of management/executive, management and project champion/working group. 26 Health Impact Assessment (HIA) A combination of procedures, methods and tools by which a policy, program or project may be assessed and judged for its potential, and often unanticipated, effects on the health of the population. Mahoney,M.,et al, Health Impact Assessment Research Unit, Deakin University (2005). Quote cited from Mahoney and Durham (2002).

40 Service Access Models: A Way Forward Resource Guide for Community Health Services Challenges When an organisation embarks on a journey to select or improve a service access system, some challenges become evident immediately while others emerge over time Authority structures Staff delegated with the task of implementing a new system, require the backing and authority of management and the assurance of ongoing support throughout the process. Uncertainty or inconsistency around support creates additional barriers and constraints that may cause confusion, unnecessary delays or staff disenchantment Role boundaries Clarifying boundaries between and flexibility around IC, INI and service-specific assessment is important. As this is an area where the lines of practice can be blurred and workflow issues can arise, clarity around these boundaries is of strategic importance and needs to be given high priority Trust issues The cultivation of trust is a sensitive matter. This is particularly so for practitioners in developing confidence in staff from different disciplines who may be undertaking INI, performing risk assessments or making appointments on their behalf. Understandably, practitioners may be concerned that consumer care is not compromised by any change to organisational process. Practitioners should work closely with service access coordinators when developing service guides, risk assessment criteria and suitable responses and making decisions affecting direct service delivery. The essential role of IC or Reception staff must also be supported, and links established and maintained between IC staff and INI staff, where those elements are conducted separately. The myriad of informal, ill-defined INI, risk assessment and appointment processes within existing systems that are often performed by reception staff - with practitioners either unaware or unperturbed - can also impact on trust between organisations. Clear guidelines are required to ensure clarity and boundaries around the IC role, as well as to support IC staff in their response to urgent or demanding enquiries. Ongoing review and communication between teams regarding potential improvements should occur as standard continuous improvement practice Staffing Staffing is a complex issue requiring consideration of several factors. To achieve successful transition, some perceptions may need to be anticipated and sensitively managed. Examples include: 27 Staff may perceive the current systems to be more than adequate and have little access to information about consumer perspectives that might signal a need for change It may be difficult for individual staff members to see the potential benefits flowing from the effort Those involved in service delivery work to the best of their ability and significant change can be perceived to suggest that their performance has been inadequate 27 Adapted from Southern Health Primary Care, Defined Points of Access Project concepts paper (unpublished draft, July 2006). HDG Consulting Group

41 Service Access Models: A Way Forward Resource Guide for Community Health Services 35 Staff generally have fairly fixed perceptions about the level of change that is possible Practitioners may not be accustomed to the transparency that comes with making information about all appointments widely available An integrated system is often perceived to reduce flexibility at the individual client or individual practitioner level Strong change leadership accompanied by a comprehensive communication and consultation strategy can help adjust perceptions and smooth the transition process Issues around client ownership and control may also exist and need to be challenged. Strong change leadership accompanied by a comprehensive communication and consultation strategy can help to adjust these perceptions and smooth the transition process. Emphasising the drivers for change and the high value placed on practitioner roles are important elements to address. Other staffing factors to consider are: The most suitable staffing option to support a model: whether to operate with a dedicated or rotating option which functions are to be undertaken by highly skilled, experienced practitioners and which by administrative staff. Task breakdown, workflow issues and role delineation Review and potential redevelopment of staffing profiles Updating position descriptions to ensure that all staff are aware of their role in Service Coordination Backfill, shadow rostering or alternative measures to address unplanned or extended leave Provision of appropriate training and ongoing workforce development, including for backfill or shadow staff Ensuring consistency of practice and completion of tasks by rostered staff or backfill staff Appropriate supervision and stress management support with managing workload pressures from dealing with high demand for services, complex needs and crises, even though much is routine For dedicated positions: well articulated position descriptions with clarity around role delineation recruitment and retention of competent staff with appropriate qualifications, skills and experience to match responsibilities structuring positions that involve working primarily over the telephone to provide job variety and satisfaction Use of SCTT and ereferral It is important to ensure that staff understand the role of tools and systems that help facilitate consistent service access, particularly how they are simply supporting resources rather than the core focus of Service Coordination. Understanding the distinction between Service Coordination and use of the SCTT and ereferral is particularly important. While the SCTT and ereferral are important tools and systems that facilitate the documentation and sharing of consumer information, it must be emphasised that they are simply resources to help achieve the core Service Coordination goal of improving consumer access to services, which should be the central focus.

42 Service Access Models: A Way Forward Resource Guide for Community Health Services Identification and management of risk The Desirable Service Coordination outcomes in Part 2 lists features that can support risk management. For more detail about risk management in community health, refer to the Clinical risk management in community health framework produced by the Clinical Governance Steering Group of Community Health Victoria, Victorian Healthcare Association Ltd (VHA). This can be accessed at the VHA website at Overview of a suggested change management process Implementation of an integrated service access model takes time, as change does not happen overnight. Appendix 6 outlines a suggested change management process. This is not an exhaustive list and need not be followed sequentially, but should be a helpful guide to planning a change management process. Some organisations may find that certain steps may not be necessary or that the sequence may need to be altered. Other helpful frameworks, sample work plans and consumer pathways can be found in the Toolkit.

43 Service Access Models: A Way Forward Resource Guide for Community Health Services 36 Supporting staff with this can involve: ensuring all staff complete the online statewide Service Coordination Self-Paced Training Module and understand their role developing clear procedures around consistent use of SCTT in a variety of circumstances, for example, for internal and external referral encouraging as many referral partners as possible (via PCP relationships) to practice according to the Victorian Service Coordination Practice Manual, and ensuring infrastructure, training and leadership encourages ongoing uptake of ereferral, where available, and meeting any agreed targets Consumers Available data indicates that most consumers find their needs are well met through accessing integrated service access systems (please refer to section 1.5). The application of clear guidelines minimises any potential consumer frustration that may arise from speaking to more people than they wish to. For example, outlining when it is appropriate for an IC staff member to make appointments directly to a service without unnecessarily referring a consumer to INI, or ensuring that consumers are offered a choice whether to accept the opportunity to partake in a broad based discussion regarding their health and wellbeing or not Multi-site factors When adopting an integrated service access model across multiple sites, consideration should be given to: adopting a Single or Parallel Access system to ensure provision of a universal, consistent response and access to services across sites/services adopting consistent practices and procedures across sites/services flexible staffing arrangements appropriate and timely sharing and transfer of consumer calls, consumer information and client files balance between availability of an in person or telephone response appropriate infrastructure to support an integrated approach Infrastructure Infrastructure needs to be considered in relation to office space and set up and systems. To ensure privacy requirements are met, office space may need to be reconfigured, which may incur costs Appropriate accommodation provides space for consumer interaction, staffing, fax machines and computers to manage consumer data and/or ereferrals, and paper-based service information It is recommended that accommodation is not isolated and is located close to a reception area Layout provides for safety i.e. has two exits and safe furniture etc Telephone and communication systems should be reviewed to ensure they can accommodate the volume of calls and associated links. Hands-free headsets assist with comfortable use of the telephone Information management systems should be reviewed to ensure they support workflow.

44 Part 5 Evaluation Part 5 Evaluation

45 Service Access Models: A Way Forward Resource Guide for Community Health Services Evaluation The importance of an evaluation process, ongoing monitoring and improvement cannot be underestimated. It provides focused opportunity to measure the impact of service access model implementation and ensures that change management processes are effective. An evaluation and monitoring process provides important indicators of progress and identifies achievement of key milestones. It also provides direction for future planning around ongoing resource allocation, service provision and that ensuring appropriate risk management strategies are in place. Any evaluation and monitoring process should be consumer outcome focused and should highlight improvements or gaps in the consumer experience around accessing services. It should measure the alignment of practice and information management, ensuring that consumers are actually experiencing clear entry points, needs identification, referral pathways and other Service Coordination processes that are easy to navigate, transparent and consistently applied. The evaluation and monitoring process is an important aspect of continuous quality improvement. Therefore, it should be undertaken in alignment with required quality standards for the organisation and the Victorian Service Coordination Practice Manual Continuous Improvement Framework. 5.1 Key evaluation considerations Decisions on the purpose, extent and nature of an evaluation are critical, as evaluations can be resource intensive and time consuming to undertake. Well developed evaluation frameworks need to be used to capture the elements of service access system implementation. At the same time, the tools for conducting an evaluation should be kept simple to ensure capture of maximum data and information. Additionally, health impact assessments complement evaluation and analysis of initiatives by capturing information on intended and unintended health and social outcomes 28. Conducting an evaluation is a whole-of-organisation process. Engagement of management, key staff and all stakeholders is imperative. Evaluation planning is best conducted in parallel with program planning. Plan to undertake an evaluation of the service access system shortly after all services are on board, and incorporate any necessary changes into the operation of the system following the evaluation. 5.2 Types of evaluations A large body of work has been undertaken around evaluation processes in the health promotion area and is most informative for developing an evaluation framework for assessing service access systems. There are three broad types of evaluation: process impact outcome 28 Mahoney,M.,et al, Health Impact Assessment Research Unit, Deakin University (2005)

46 Service Access Models: A Way Forward Resource Guide for Community Health Services 39 Table 5.1: Types of evaluation Type of evaluation What it does How it may be used Process evaluation Impact evaluation Outcome evaluation Assesses the elements of service/program development and delivery, that is, the quality, appropriateness and reach of the service/program Note: Process evaluation data is critical in understanding, interpreting and explaining much of the data collected through impact and outcome evaluation. Measures the immediate effects on organisation/services/ programs assessing the degree to which organisation/service/ program objectives are affected (at service access model selection stage) or where met by the model following implementation. Note: organisation/service/program objectives should be developed and written in a way that enables judgements about whether, and to what extent, they have been achieved. For example: using the SMART approach (see below). Measures the long term effects of services/programs and is informed by process and impact evaluations. Note: Important and advisable to document relevant outcomes and findings where possible. Can be used during the entire life of the service, from planning through to the end of delivery. Is useful during planning and piloting stages, focuses on the quality and appropriateness of materials and approaches being developed. In the implementation stage is useful in tracking the reach and level of implementation of all aspects of the service, and in identifying potential or emerging problems/risks. Can be used either at the selection stages of change management or at the completion of implementation. Can be used to assess impacts on: consumers staff organisation services/programs practices other organisations demand management records management, etc. Enables judgements about whether, or to what extent, a service/program goal has been achieved. (Adapted from Department of Human Services Planning for Effective Health Promotion Evaluation, May and the Whitehorse Community Health Service Health Promotion Resource Manual 30 ) The SMART approach is an effective way to develop sound objectives to guide evaluation of impacts on service delivery. This approach emphasises developing objectives that are: Specific Measurable Achievable Relevant Time specific - clear and precise - amenable to evaluation - realistic - to the services/programs/organisation - time frame for achieving the objectives 29 State Government of Victoria 2005, Planning for effective health promotion evaluation, Department of Human Services, Melbourne 30 Whitehorse Community Health Service, undated, Whitehorse Community Health Services health promotion resource manual, unpublished,

47 Service Access Models: A Way Forward Resource Guide for Community Health Services 40 Elements of the draft Victorian Service Coordination Practice Manual and Continuous Improvement Framework and practice standards can be used to guide development of service access model evaluation objectives in addition to more specific elements. Health impact assessments Health impact assessments can contribute to the selection and evaluation of a service access model by measuring client health impacts resulting from the changes brought about by implementing a model. Health impact assessments are useful in the change management process to predict or estimate the consequences of a course of action (project, policy, technology) 31. This process is supported by further impact assessment following model implementation to examine outcomes such as 32 : balance of costs/benefits and acceptance environmental soundness of proposals avoidance of adverse impacts maximisation of benefits addressing health inequalities. A variety of methods can be used to conduct assessments, such as: record keeping and documentation observation surveys (consumers/staff) requires well constructed questions focus groups interviews. Organisation example - Peninsula CHS: 33 Method We adopted a participant-oriented model as our evaluative strategy. This model emphasises the central importance of the evaluation participants, especially clients and users of the program or technology. We conducted an impact evaluation designed to assess the extent to which the Client Access System has impacted upon on our overall objective of enhancing ease of access for clients to our services. We did this by facilitating semi-structured focus group discussions with representative groups of staff and clients of the organisation. We also conducted interviews with individual staff members with a view to maximising service provider input. Every worker in the agency was invited to participate. The representative groups within the agency comprised: clients access workers administration workers management team service providers. Groups of questions were developed for the key stakeholders. They were structured to compare and contrast the experience of stakeholders with respect to the objectives, and then to provide specific opportunities for reflection on the system from their differing role perspectives. In order to provide clients with an opportunity to give objective feedback on their experience of gaining access to our services, a social work student was invited to conduct a survey with them, using a semi-structured telephone interview. 31 and 32 Mahoney,M.,et al, Health Impact Assessment Research Unit, Deakin University (2005) From Barrow (1997, p. 6) 33 Peninsula CHS 2001, Client Access System Evaluation, unpublished.

48 Service Access Models: A Way Forward Resource Guide for Community Health Services Evaluation planning framework Diagram 5.1 sets out the stages of evaluation development 34. Although developed for health promotion initiatives, it is equally applicable to evaluation of service access models. It describes the elements of a clear, stepped evaluation process and is supported by several evaluation planning keys. The following pages apply the steps to the evaluation of service access models. Diagram 5.1 Evaluation planning guide 34 State Government of Victoria 2005, Planning for effective health promotion evaluation, p 6

49 Service Access Models: A Way Forward Resource Guide for Community Health Services Evaluation planning keys 35 Step 1 - Describe the service access model, identifying goals, objectives Be clear about broad priorities and use these to develop service access model, goals and objectives. Analyse determinants of service access model and service/program priorities as a starting point for developing objectives. Write goals and objectives to guide the evaluation process. These should be clear, concise, achievable and measurable (SMART). Estimate impacts of objectives of the service access model. Key questions to consider when identifying impacts include: How are we going to know when we have reached our objective? What impact indicators will be appropriate to measure the degree to which the service access model objectives have been met? Has the service access model been implemented as planned? What worked well and what could be done differently? Have any unexpected problems arisen? Are there any adjustments that need to be made? In measuring impacts and outcomes, revisit the original goals and objectives. Clearly describe how you plan to conduct the evaluation and implement any subsequent strategies arising from the evaluation. Step 2 - Evaluation preview Active participation of key stakeholders is a critical component of successful service access model implementation and evaluation and gaining agreement on key aspects. Clarify the purpose of the evaluation. Planning and conducting an evaluation needs clear direction and vision. Key questions to assist in determining the type of evaluation include: What is the purpose of the evaluation? What do we want the evaluation achieve? Who is the evaluation for? (this may predetermine findings reporting mechanisms) What questions need to be answered? What processes or impacts would be most useful to monitor/examine? What is the resource impact of the evaluation? What information do we need? (major task is to develop a set of key questions to be answered by the evaluation) What resources, skills, opportunities and time are available for the conduct of the evaluation? The nature and purpose of an evaluation should be determined early in the process of implementing a service access model. 35 Adapted from Oldenburg et al (1997), as cited in NSW Health and Australian Health Promotion, Australia.

50 Service Access Models: A Way Forward Resource Guide for Community Health Services 43 Step 3 - Focus the evaluation design Identify the information needed to answer these questions (the overall evaluation design should generate this information). Evaluation designs include: quantitative method (relies on collection of numeric data) qualitative method (relies on collection of written or narrative data from structured, semi-structured and unstructured processes such as interviews, case studies, surveys). Step 4 - Coordinate data collection The essential elements of coordinated data collection include: the tasks to be completed who should undertake the tasks when the tasks should be undertaken the resources required. To ensure a useful response, the evaluation participants should have some ownership of the process. Step 5 Analyse and interpret the data Study the data to identify, summarise and interpret the: key findings themes (classify and group data to identify key themes) information evidence/examples. Step 6 Disseminate lessons learnt Determine if the evaluation data findings provide answers to the questions cited in Step 1: Has the service access model been implemented as planned? What worked well and what could be done differently? Have any unexpected problems arisen? Are there any adjustments that need to be made? Consider the types of reports to be prepared containing the findings. Dissemination of the findings is crucial to providing an evidence base for Service Coordination improvements or issues. Some questions to shape your reporting and dissemination strategy include: Who should have access to the results of the evaluation and what is an ideal format for ensuring adequate and accessible information? How will evaluation data be used and stored within the organisation to ensure that future programs are able to build on the knowledge base achieved during the evaluation? How could or should results be distributed more widely so that other organisations are able to know about your work?

51 Service Access Models: A Way Forward Resource Guide for Community Health Services 44 Dissemination strategies can include: training print communication electronic communication face-to-face consultancy policies, administrative arrangements and funding incentives committee and other decision making structures. Factors supporting successful dissemination include: involvement of key stakeholders dissemination expected, planned for and funded active supportive dissemination and uptake ongoing access to resources publicity strategies for dissemination and skill development political agenda. 5.5 Evaluation tools The decisions and outcomes of any evaluation process need to be summarised and presented to inform day-to-day decision making and actions. Evaluation tools assist in documenting findings in a straightforward way that encourages tracking of follow-up decision making and actions arising. The Victorian Community Health Association s Quality Improvement Program Planning System (QIPPS) consists of a set of planning and evaluation tools, a web-based library, a help desk and other contacts and resources, with a focus on health promotion and Community Development. It can be accessed at The following sample grid is a suggested method of summarising the evaluation planning process. For each service access model objective and its associated impacts, the grid poses key questions that serve as the focus of: the evaluation the information needed to answer the questions the data collection method the budget information to support the process. The grid also provides for the answering of key questions related to the project, as distinct from questions about program/service specific objectives. It also contains planning space for the preparation and dissemination of a report.

52 Service Access Models: A Way Forward Resource Guide for Community Health Services 45 Table 5.2: Sample Evaluation planning process grid 36 Priority: Service access system Program/ service Goal: To establish an integrated service access model incorporating all organisation services Dental Objective 1 Incorporate dental services into the organisation s service access model Key questions: What do we need to know to decide if we have achieved this objective? What processes or impacts would be most useful to monitor/examine? What information do we need to answer these questions? How will this information be collected, by whom and by when? Budget Impact/s Process evaluation Impact evaluation Outcomes evaluation Objective 2 Ensure all dental clients are provided with INI if desired, particularly those with complex or chronic needs Key questions: What do we need to know to decide if we have achieved this objective? What processes or impacts would be most useful to monitor/examine? What information do we need to answer these questions? How will this information be collected, by whom and by when? Budget Impact/s Process evaluation Impact evaluation Outcomes evaluation Additional key questions Overall aspects of the initiative For example: What has worked, what hasn t, what could be done differently? Preparation of evaluation report For example: What are the key findings, themes, information, evidence/examples, strategies we want in the report? Dissemination For example: Who should have access to the results of the evaluation and what is an ideal format for ensuring adequate and accessible information? More detailed information about evaluation processes may be obtained from Planning for effective health promotion evaluation (Department of Human Services 2005) at: and Integrated health promotion resource toolkit (Department of Human Services 2003) at: df 36 Adapted from State of Victoria (2005), Planning for Effective Health Promotion Evaluation, Department of Human Services

53 Service Access Models: A Way Forward Resource Guide for Community Health Services 46 Glossary Access The right of, opportunity and means for entry to services. Access points Agency Points of entry that facilitate consumer navigation and access to the broad service system and not limited to facilitating intake into (or exclusion from) one particular organisation. Service provider, organisation. Assessment A decision-making methodology that collects, weighs and interprets relevant information about the consumer. Assessment is not an end in itself but part of a process of delivering care and treatment. It is an investigative process using professional and interpersonal skills to uncover relevant issues and to develop a care plan. BATS strategy Better Access to Services. The policy and operational framework that will assist Primary Care Partnerships (their organisations and the organisations practitioners) to achieve functional integration. Functional integration will be facilitated through a systemic and consistent approach to assessment and service delivery. The agreed proposal for the ongoing planning, implementation and management of the Better Access to Services Operational Framework as part of each Primary Care Partnership s Service Coordination model. The Better Access to Services strategy is part of the Primary Care Partnership Community Health Plan, and is based on a shared agreement about the Service Coordination model. The purpose of this strategy is to improve people s access to services and hence improve health and wellbeing outcomes. Best practice A concept of organisational change and improvement that has been adopted from the industrial sector where it is seen as the pursuit of world class performance. Best practice is considered to be a comprehensive integrated and cooperative approach to the continuous improvement of all facets of an agency s operations. Care Assistance or support given to a person to improve their health, functional ability and wellbeing and to help them achieve maximum quality of life. Care planning (CP) A dynamic, consultative process that includes the consumer, the family and appropriate agencies in the identification and assessment of consumers needs, from which a care plan is developed, that includes goals and actions aimed at achieving desired/optimal outcomes. Key tasks include: Identification and assessment of short term and long term consumer strengths, resources and needs. Prioritising of consumer needs and goal setting to meet such needs.

54 Service Access Models: A Way Forward Resource Guide for Community Health Services 47 Exploring the most appropriate and cost-effective way of meeting consumer needs. Developing a Care Plan specific to the services of the agency, noting other agencies involved. The circulation of this plan will depend on current individual agency practices. Implementing the Care Plan. Ongoing assessment and review of consumer needs and appropriate revision of the Care Plan. Carer Anyone who provides unpaid assistance to a person with support needs based upon a previously existing relationship. Usually a partner or a family member but can also be a friend, neighbour, work colleague or other acquaintance. The informal carer can provide a little or a lot of assistance in terms of tasks undertaken or time spent providing care. Competencies The ability to perform the activities within an occupation or function to the standard expected in employment. Comprehensive assessment A face-to-face interaction with a consumer, involving an intense level of inquiry and an advanced dimension of history taking, examination, observation and measurement/testing. It facilitates a more extensive process of inquiry that requires analysis and interpretation of the assessment information and a clinical judgment, diagnosis and differential diagnosis. A comprehensive assessment usually involves a multidisciplinary team. Consent Consumers The voluntary agreement of the individual or the individual s authorised representative about a proposed action. It can be either express or implied. Express consent is provided explicitly, either orally or in writing. It is unequivocal and does not require any inference on the part of the agency seeking consent. Implied consent arises where consent may be reasonably inferred from the action or inaction of the individual. Consent must be meaningful, that is, an individual must understand what has been consented to and the implications of this. Consent must be obtained without coercion or undue influence. Those members of the community who currently use services, are seeking to use services or who are potential service users - patient, client, carer, family. Duty of care A duty to take reasonable care of a person. A duty of care is breached if a person behaves unreasonably. Failure to act can also be unreasonable in a particular situation. A duty of care can be breached either by action or inaction. The reasonableness of what a person has done or not done, is assessed by considering how a hypothetical reasonable person would have behaved in the same situation. What is considered reasonable will depend on the circumstances. Electronic referral (ereferral) Referral using one of the electronic referral systems operating in Victoria.

55 Service Access Models: A Way Forward Resource Guide for Community Health Services 48 Functional integration A form of integration in which agencies and services continue to operate as independent entities but agree to work in a cohesive and coordinated way to ensure that consumers experience a seamless and integrated response. Agencies may undertake particular functions (for example: Initial Contact, Initial Needs Identification) in a common, integrated manner. Under functional integration, agencies continue to operate within their existing organisational and structural arrangements and simultaneously work within the virtual organisation of a Primary Care Partnership. HACC Health Home and Community Care program A complete state of physical, mental and social wellbeing, not merely the absence of disease or infirmity. A state of wellbeing in which the individual realises his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community. Health information Includes personal information that is information or opinion about an individual s physical, mental or psychological health; a disability of an individual; an individual s expressed wishes about the future provision of health services to him or her; a health service provided to the individual. It also includes information that is collected to provide a health service, collected in connection with the donation of body parts and/or genetic information in a form that is, or could be, predictive of the health of an individual or any descendants. Health information refers to a person s health information in any form (written, verbal, electronic, on video etc). Health promotion (HP) The process of enabling people to increase control over, and to improve, their health. To reach a state of complete physical, mental and social wellbeing, an individual or group must be able to identify and realise aspirations, to satisfy needs and to change or cope with the environment. Information management (IM) The practices, protocols, roles, responsibilities and business processes that support the management of information (personal information, health information, services information, financial and administrative information, planning and performance monitoring information), whether in electronic or other form. Initial Contact (IC) The point of first contact with the service system and will most commonly include the provision of accurate service information, the provision of other information such as health promotion literature, and/or direct access to services via an Initial Needs Identification.

56 Service Access Models: A Way Forward Resource Guide for Community Health Services 49 Initial Needs Identification (INI) An initial screening process where the underlying issues as well as presenting issues are uncovered to the extent possible. It is not a diagnostic process but a determination of the consumer s risk, eligibility and priority for service and a balancing of the service capacity and the consumer s needs. Acronyms and Common Terms Intake A discrete component of service access work that relates specifically to acceptance by an organisation of a request for service, and the arranging of subsequent service provision within that organisation. Integrated Two or more elements, functions or processes combined in order to become more effective. Integrated service access model - Single Access system A service access model with a single discrete access point, characterised by systematic and consistent practice for all programs/services. Integrated service access model - Parallel Access system Non-Integrated service access model A service access model with a combination of discrete access point(s) for most services/programs (organisation/site/lga/region based) and additional, discrete program/specialist/service-specific access point(s). Characterised by integrating mechanisms that support systematic and (mostly) consistent practice for all programs/services. A service access approach with multiple access points, characterised by variable, inconsistent practice per practitioner, discipline, program or site. Coupled with a limited focus on facilitating intake into (or exclusion from) one particular organisation s services, this historically dominant model presents challenges in the current policy environment and direction for seamless consumer care. Operational framework A general description of the six elements of Better Access to Services in which functional integration will be achieved. The six elements are: Initial Contact, Initial Needs Identification, service-specific assessment, specialist assessment, comprehensive assessment, and care planning. Organisation Agency. Practitioner A service provider who has direct contact with, and provides direct service to, consumers - health professional, doctors, specialists, nurses, allied health professionals, case managers, counsellors, welfare workers, community care workers, service provider and front of house staff, etc. PCP Strategy Primary Care Partnership Strategy. A strategy that aims to facilitate collaboration and partnerships between primary care services within a defined catchment to maximise positive outcomes for consumers and deliver improved health and wellbeing for the community. This strategy provides a

57 Service Access Models: A Way Forward Resource Guide for Community Health Services 50 framework for improving the planning and delivery of primary care services and for ensuring they work effectively together. Primary care Primary care is essential health care based on practical, scientific and socially acceptable methods and technology. It is made universally accessible to individuals and families in the community through their full participation and at an affordable cost to the community and country. Primary health care is the central function and main focus of the country s health system. It is the first contact of the individual, the family and the community with the national health system, bringing health care as close as possible to where people live and work. Providers Organisations funded to provide services to consumers. Referral The transmission (physically or by other means) of personal and/or health information relating to an individual from one agency to another agency(s), with the individual s consent and for the purpose of care or treatment. Review Formal follow-up of a consumer, usually on a date specified in the care plan, or due to a sudden change in the consumer s situation, where the suitability of the care plan in meeting the needs of the consumer is considered. Risk assessment A systematic process that quantifies the level of the consumer s risk. Risk assessment tool A structured way of identifying consumers who are at risk of developing a specific condition. Screening A process that involves the systematic use of a test or investigatory tool to detect individuals at risk of developing a specific disease that is amenable to prevention or treatment. It is a population-based health strategy to identify specific conditions in targeted groups prior to any systems appearing. Service access model A systematic, consistent and integrated approach that provides systematic consumer needs identification and access to services, including but not limited to intake into a single organisation s services. Service access system The organisational structures and arrangements that support operation of a service access model. Service access work Functions or activities that are undertaken to support consumer needs identification and access to services. Service Coordination The Service Coordination element of Community Health Plans provides a framework whereby local models, systems and processes for assessment and information management, facilitate functional integration across the range of services. This means that whilst services remain independent of each other in a structural sense, they work in a cohesive and

58 Service Access Models: A Way Forward Resource Guide for Community Health Services 51 coordinated way so that the consumer experiences a seamless and integrated response. Within the service coordination component of community health plans, there are three initiatives that provide the infrastructure. These initiatives are Better Access to Services, Information Management and Local Services Information and are interdependent. The purpose of service coordination is to improve people s access to services by making the service system function transparently to its local community. Service Coordination Tool Templates (SCTT) A statewide suite of forms or tools that support Service Coordination practice by assisting with identifying the initial (or subsequent) needs of consumers, and providing a vehicle to collect and share core consumer information in a consistent way. SCTT Guidelines provide information about the purpose and use of the SCTT, but the practice change required is determined by the Victorian Service Coordination Practice Manual and local Primary Care Partnership or regional agreements between agencies, known as practices, protocols, policies and systems (PPPS). The Service Coordination Tool Templates: Support consistent Service Coordination practice Collect core consumer information Determine consumer needs, risks and urgency Support appropriate referral, assessment and care planning Service Directory A comprehensive information source on the range and scope of health and community based services available to consumers to be used to inform consumers and practitioners. Service Specific Assessment Service Specific Assessment is a face-to-face interaction undertaken where consumers have a relatively straightforward, obvious and distinct need for a specific service. It is conducted by the provider responsible for delivering the service and occurs as part of the delivery of service. Social model of health A conceptual framework within which improvements in health and wellbeing are achieved by directing effort towards addressing the social and environmental determinants of health, in tandem with biological and medical factors. Specialist Assessment Specialist Assessment is a face-to-face interaction with a consumer and is undertaken where the presenting issue clearly requires a specialist service response. It occurs where a specialist need is identified following Initial Needs Identification.

59 Appendices 1. Where to learn about Service Coordination 2. Policy context 3. Hypothetical structural designs 4. Models Comparative Chart 5. Staffing Comparative Chart 6. Change Management Chart Appendices

60 Service Access Models: A Way Forward Resource Guide for Community Health Services 52 Appendix 1 Where to learn about Service Coordination The following diagram depicts the resources and tools that support effective embedding of Service Coordination.

61 Appendix 2 Additional policy context from a Service Coordination perspective In addition to the release of the BATS strategy in 2001 and the Care in Your Community - a planning framework for integrated ambulatory health care framework in 2006, many other government policies and associated reform initiatives incorporate and build upon the Service Coordination emphasis of improved consumer needs identification and access to services. A summary of how some key initiatives relate to Service Coordination is provided below, and links to these documents can be found on the Policy and context documents page. Diagram A2.1: State policy context for Victorian primary health programs Growing Victoria Together A vision for Victoria to 2010 and beyond A Fairer Victoria Creating opportunities and addressing disadvantage Care in your community Community Health Policy Primary Care Partnerships Strategy Growing Victoria Together 37 provides a whole of government policy framework that integrates and shapes the policies and plans for the future of Victoria s health services. One of the key priorities is the achievement of high quality, accessible health and community services. The framework recognises that this requires strategies that improve local access to essential health, aged care and community services. A Fairer Victoria 38 is a long-term action plan by the Government to tackle disadvantage and increase opportunities for all Victorians. It highlights the need for locally appropriate policy responses and flexible ways of delivering services. One of the key platforms is to reduce barriers and improve access to quality services, particularly for disadvantaged groups in the community, which an integrated service access model can achieve. 37 State Government of Victoria 2001, Growing Victoria Together: A vision for Victoria to 2010 and beyond, Victorian Department of Premier and Cabinet 38 State Government of Victoria 2005, A Fairer Victoria, Victorian Government s Social Policy Action Plan, Victorian Department of Premier and Cabinet

62 Service Access Models: A Way Forward Resource Guide for Community Health Services 54 The Community Health Services - creating a healthier Victoria 39 policy refers to the need to fully implement the Service Coordination initiative as a component of the key strategic direction to strengthen CHSs as a major platform for delivery of primary health care and community support (p 22). Primary Care Partnerships - strategic directions emphasises the importance of greater integration across acute and primary health care services to better meet the needs of consumers, particularly those with chronic or complex health problems. It confirms a vision for Primary Care Partnerships (PCPs), including a clear commitment to consistent service development and the achievement of improved service access and coordination for consumers. The vision is for: improved Service Coordination practices being enhanced and embedded in agency practice the streamlining of assessment and service access for consumers reliable information and communication technology (ICT) infrastructure, and agreed standards in place enabling electronic communication, including e-referral flexible funding to assist innovation and integration of services. Future strategic directions will remain consistent with this Service Coordination approach. Making it work improving access to services for clients in community health 41 provides a snapshot of how five CHSs successfully changed the way they do business to realise the service objectives. It describes the Service Coordination model introduced by the organisations and includes what they achieved, some of the challenges, the change process and lessons learnt along the way. The Analysis of the impacts of Service Coordination on service capacity in the primary health sector 42 undertaken by KPMG, further identifies factors impacting on Service Coordination implementation in several CHSs and local councils, and makes recommendations to Department of Human Services around continued promotion, support and expansion of Service Coordination. The Chronic Disease Management Program Guidelines for Primary Care Partnerships and Community Health Services 43 support PCPs, their member organisations and CHSs in the development of chronic disease management (CDM) across the service system. The guidelines require CHSs to work on internal system changes to deliver the CDM model of care developed with the PCP and other key organisations, and facilitate service system integration by developing systems that support a coordinated approach to the planning and delivery of services for clients with chronic disease. This includes ensuring that comprehensive and robust practices, processes, protocols and systems (PPPS) are in place as part of the Service Coordination strategy, to minimise fragmentation across the service system and ensure that clients receive appropriately coordinated and integrated services in a timely, efficient and seamless manner. The guidelines should be used in conjunction with additional resource materials that will subsequently be released. Strategic directions in assessment, Victorian Home and Community Care Program Final report 44 outlines key issues and patterns of current practice in assessment and proposes a three-year plan for the development and implementation of a HACC Assessment Framework. The revised policy guidelines on assessment practice identify home-based assessment as the preferred setting for assessment. The Framework for Assessment in the 39 State Government of Victoria 2004, Community Health Services: creating a healthier Victoria, Primary and Community Health Branch, Victorian Department of Human Services, Melbourne 40 State Government of Victoria 2004, Primary Care Partnerships strategic directions : Better health stronger communities, Victorian Department of Human Services, Melbourne 41 State Government of Victoria 2004, Making it work improving access to services for clients in community health, Victorian Department of Human Services, Melbourne 42 KPMG 2004, Analysis of the impacts of Service Coordination on service capacity in the primary health care sector Final Report (KPMG). Victorian Department of Human Services, Melbourne 43 State Government of Victoria 2006, Chronic Disease Management Program Guidelines for Primary Care Partnerships and Community Health Services, Primary and Community Health Branch, Victorian Department of Human Services, Melbourne 44 State Government of Victoria 2005, Strategic directions in assessment, Victorian Home and Community Care Program Final report. Home and Community Care Program, Victorian Department of Human Services, Melbourne

63 Service Access Models: A Way Forward Resource Guide for Community Health Services 55 HACC program is currently being finalised. The Framework sets out revised policy requirements for delivering home-based needs assessment and related processes such as consumer care coordination for consumers with complex needs and circumstances. The Assessment Framework is a critical element in refocussing the HACC Program's model of service delivery around improving client independence wherever possible, through a more active model of service. The draft Framework for Assessment in the Victorian Home and Community Care Program 45 sets out program policy for all types of assessment in HACC and related processes. It describes the requirements for delivering home-based needs assessment as a funded activity. The Waiting time measurement within community health services practice guidelines 46 outline the commencement of a more robust approach to demand measurement and management in CHSs. A standardised demand management model will be identified that addresses waiting list definition, categorisation and management of Community Health program allied health, counselling and nursing services at a statewide level. This will require CHSs to reflect on the way they do business and move toward HealthSMART, in which an electronic environment is primary practice. Consistent Service Coordination practices can inform quality demand measurement and management, resulting in useful and powerful information collection. Such information can identify local resource allocation and service planning issues, promote good practice strategies for managing high demand and provide evidence to inform decisions about government funding priorities. HealthSMART Patient and Client Management Systems project - two new patient management and client management systems are being introduced to support all functions associated with the administration and management of patients and clients. The replacement of the current Patient Administration Systems and implementation of a client management system across the major community agencies is currently being rolled out to support the reformed service delivery model. isoft will provide the integrated patient and client management system, while TrakHealth will implement the stand-alone client management systems in community health organisations. Both systems will provide better function and flexibility, including enhanced statutory reporting functions, and will consolidate systems including SWITCH, ADIS and IRIS. The applications will also interface to other common health applications. Rural directions for a better state of health 47 is the Victorian Government s plan for sustaining a contemporary health system in rural and regional areas, providing high quality and appropriate health services in the best setting, as close as possible to where people live. Rural directions outlines three key directions that will position the health system to better meet the needs of rural and regional Victorian. One strategy to support Direction 2: Foster a contemporary health system and models of care for rural Victoria is the continued development of primary and community health services, including continued support of PCPs and Service Coordination. The Hospital Demand Management Strategy 48, New directions for mental health services 49 and Improving the care of older people policy 50 also reflect alignment with Service Coordination principles. 45 Framework for Assessment in the Victorian Home and Community Care Program, September 2006: Draft for comment 46 State Government of Victoria 2006, Waiting time measurement within community health services: practice guidelines. Primary and Community Health Branch, Victorian Department of Human Services, Melbourne 47 State Government of Victoria, Rural directions for a better state of health (2005), Rural and Regional Health Services Branch, Rural and Regional Health and Aged Care Services, Victorian Department of Human Services, Melbourne 48 State Government of Victoria 2001, Hospital Demand Management Strategy, Victorian Department of Human Services, Melbourne 49 State Government of Victoria 2002, New directions for Victoria s mental health services the next five years, Mental Health Branch, Victorian Department of Human Services, Melbourne 50 State Government of Victoria 2003, Improving care for older people: a policy for health services, Metropolitan Health and Aged Care Services Division, Victorian Department of Human Services, Melbourne

64 Service Access Models: A Way Forward Resource Guide for Community Health Services 56 Doing it with us not for us - Participation in your health service system : Victorian consumers, carers, and community working together with their health services and the Department of Human Services strategic direction 51 highlights consumer participation as an essential principle of health development, community capacity building and the development of social capital. The policy targets the acute and sub-acute areas of the health service system as these were identified as having a gap in participation policy, however the following three of the seven key objectives clearly link to Service Coordination principles and the community health sector: Objective One: Take participation seriously doing it with us not for us. Objective Two: Share information to create consumer and carer friendly access to services. Objective Three: Improve communication between all stakeholders. Priority actions under those objectives that relate to Service Coordination principles include: Communicate clearly and respectfully with consumers and carers. Provide accessible information to consumers, carers and community members about health care and treatment. Communicate and provide information about treatments and care to consumers and carers that is developed with consumers and, where appropriate, carers. Listen and act on the decisions the consumer and, where appropriate, their carer(s) make about their care and treatment. Create welcoming and accessible services for the diverse members of your community. Establish links with community organisations to provide emotional support and ongoing information to consumers and carers. In line with these policy directions and other work across Department of Human Services program areas, there has been increased alignment with Service Coordination principles resulting in improved links within and between sectors. Examples of these include: InterRAI Pilot for ACAS and HARP - CDM (Chronic Disease Management) HealthSMART patient and client management systems E-referral Architecture Framework Project Patient Flow Collaborative II Outpatients Centres Promoting Health Independence Mental Health Triage Redevelopment projects Alcohol and Other Drugs Service System Review project: Blueprint project and other integration activities Review of the strategic framework for Family Services Child Protection and Family Services Innovations Projects 51 State Government of Victoria 2006, Doing it with us not for us - Participation in your health service system : Victorian consumers, carers, and community working together with their health services and the Department of Human Services strategic direction, Victorian Department of Human Services, Melbourne

65 Service Access Models: A Way Forward Resource Guide for Community Health Services 57 Early Childhood Intervention Services work with Primary Health Branch to develop a Child Health and Wellbeing Profile work Family Violence integration initiatives Common Homelessness Assessment and Referral Framework Social Housing Advocacy and Support Program. Note: Related Commonwealth Government initiatives such as A new strategy for community care - the way forward 52 also reflect alignment with Service Coordination principles. This strategy outlines steps to reshape and improve the community care system for the frail aged and people with disabilities. This includes the adoption of common arrangements and consistency across all programs in areas such as access to services, eligibility, assessment, planning, quality, accountability and collection of information. Five broad areas of action are identified and work on many aspects by all governments is underway on: addressing overlaps and gaps in service delivery providing easier access to services enhancing service management streamlining Australian Government programs adopting a partnership approach. The community health sector is well placed to demonstrate leadership and provide good practice examples of the systems and infrastructure realignment necessary to improve service access and support the delivery of integrated health care to consumers. Policy and context documents Growing Victoria Together: A vision for Victoria to 2010 and beyond (2001) GVT.pdf A Fairer Victoria, Victorian Government s Social Policy Action Plan (2005) fairer%20vic.pdf Better Access to Services: A policy and operational framework (2001) BATS_Policy&op-frmewrk_July01.pdf Making it work (2004) Primary Care Partnerships - strategic directions The analysis of the impacts of service coordination on service capacity in the primary health sector (Nov 2004), KPMG report Community Health Services - creating a healthier Victoria (2004) 52 Commonwealth of Australia 2004, A new strategy for community care - the way forward, Department of Health and Ageing, Canberra

66 Service Access Models: A Way Forward Resource Guide for Community Health Services 58 Care in your community a planning framework for integrated ambulatory health care (2006) Rural directions for a better state of health (2005) Doing it with us not for us - Participation in your health service system : Victorian consumers, carers, and community working together with their health services and the Department of Human Services Strategic Directions In Assessment, Victorian Home and Community Care Program Final Report (2005) Strategic Directions in Assessment: Victorian Home and Community Care Program Final Report December 2005 (444kb, pdf) Draft Framework for Assessment in the Victorian Home and Community Care Program Waiting time measurement within community health services practice guidelines (2006) Chronic Disease Management Program Guidelines for Primary Care Partnerships and Community Health Services (Oct 2006) cdm_program_guidelines.pdf HealthSMART Patient and Client Management Systems project A new strategy for community care - the way forward

67 Service Access Models: A Way Forward Resource Guide for Community Health Services 59 Appendix 3 Hypothetical structural designs 53 There are many design configurations that can be applied when considering the linking or integration of multiple components of a service system. Design configurations can range from those that are distinct and separate through to those that are connected across one or more levels and display varying degrees of functional integration. At present, primary care services operate with varying degrees of integration at the point of access and intake. Diagram A3.1: Design configuration illustrates a range of hypothetical design configurations. It should be noted that the details, advantages and disadvantages of each have not yet been analysed in any detail. Particular consideration would need to be given to the variables of size, complexity, capacity, information technology, potential benefits/risks etc. The design configurations are presented to facilitate preliminary thinking about hypothetical options, and do not assess their feasibility in any detail. Brief commentary about the benefits and disadvantages at a conceptual level is provided. Diagram A3.1: Design configuration A) Segregated design Each individual service has its own separate segregated access and intake model. Some models may be similar and there may be some identical processes, however they are fundamentally separate in operation. Generally speaking, the benefits of this design approach are likely to be that the model can be tailored to the specific needs of individual client group and services. Disadvantages can include lack of coordination across services, access is fragmented where more than one service may be required by an individual, quality and standards can vary dramatically across services, and there may be a degree of duplication, such as in administration, records, computer systems etc. [NB: Correlates with Non-Integrated Service Access Model] B) Cluster design Access and intake for services are clustered together based on a common factor, such as a common client group, common service type, common location, common systems etc. This design is currently in use by some services whereby a central access and intake model and process enables access to a cluster or suite of services (such as CHS). The cluster of services tends to be based on the organisational structure of the unit or division of the larger organisation. Access and intake processes and systems may vary from one cluster to another (for example, different information technology software). The benefits of this design approach are likely to be a semi integrated and coordinated approach with standardisation in relation to quality processes and systems. [NB: Correlates partially with Integrated -Parallel Access Service Access Model, although is not necessarily characterised by shared set of practices and procedures or integrating mechanisms] 53 Adapted from Southern Health Primary Care Defined Points of Access project Concepts Paper (unpublished draft, July 2006). HDG Consulting Group.

68 Service Access Models: A Way Forward Resource Guide for Community Health Services 60 C) Linked cluster design This design allows the linking of multiple clusters through a specified point of access. For example, initial contact is made via a centralised point and then, based on the request/action required, this is then streamed to the appropriate cluster. A benefit of this approach is access via a single point to multiple clusters of services. An obvious disadvantage is that this can be seen to be adding another layer to the model and may result in a less streamlined and customer-friendly approach. D) Nucleus design Access and intake to services is via a defined, central point of access with services and programs grouped around it. Defined access is considered a pivotal and important central element. The design is similar in nature to the cluster design, but provides access to an increased number of programs or services, and has an increased profile. It maybe applied further upstream so that the degree of integration is increased. E) Dynamic nucleus or orchestra design The benefits of this design approach are easier access through a single, defined, centralised point to multiple primary care services. It supports a self management approach. Disadvantages can include the requirement for highly skilled staff with extensive knowledge in relation to multiple programs. [NB: Correlates with Integrated - Single Access Service Access Model] This design is similar yet more sophisticated than the nucleus design. The design is more dynamic in that it includes the capacity for monitoring the essential features of a client journey. Highly skilled staff have a key role in orchestrating the response to the person and monitoring the client journey through and around the system. High quality and integrated information technology systems underpin this approach. The benefits of this design approach are easier access through a single, defined, centralised point to multiple primary care services, plus a monitoring component to check the smooth movement of the person through the system. F) Overlap design Access and intake to services is a blend of horizontal and vertical integration that may occur to different degrees across different programs. There are some aspects which overlap and others do not. This is the most complex and complicated both from a practitioner and consumer perspective. Generally speaking, the benefit of this design approach is integrated access to overlapping services. Disadvantages can include that access is more difficult to services that do not overlap. HDG Consulting Group 2006

69 Service Access Models: A Way Forward Resource Guide for Community Health Services 61 Appendix 4 Service access models comparative chart Elements Features Integrated Non Integrated Legend: Single Parallel Multiple access Applies Access system Access system points * Particularly relevant for rostered or allocated activity staffing options Particularly relevant for dedicated staffing option ~ Possibly Historically Integrated: dominant model Single Access system - Single discrete access point regardless of the number of sites. Characterised by systematic and consistent practice for all programs/services Parallel Access system - Combination of discrete access points for most services/programs (organisation/site/ LGA/region based) and/or additional discrete program/specialist/ service-specific access point(s). Characterised by integrating mechanisms that support systematic and (mostly) consistent practice for all programs/services Non-Integrated: Multiple access points characterised by variable inconsistent practice per practitioner/discipline/program (historically dominant model ) Strengths Improves access for consumers by providing clear access points and referral pathways Enhances identification of broad consumer needs and prioritisation of access at earliest point of contact Enhances consumer navigation through system and supports assisted referrals Streamlines navigation/intake and referral processes for consumers and service providers Supports appropriate eligibility screening and early intervention for targeted consumer groups Reduces response times to consumer enquiries Improves equity of access to services through consistent application of clear eligibility criteria Increases capacity to facilitate consistent response to both telephone and walk in consumers Supports development and consistent application of clear IC, INI and referral policies and processes Supports development and consistent application of clear intake policies and processes Supports consistent application of privacy principles Activity is focused on core Service Coordination processes Increases capacity to provide brief interventions at INI, for example, telephone counselling ~ ~ ~ Increases capacity to provide early health promotion interventions at INI Supports a centralised, integrated appointment system ~ ~ ~ Improves capacity for consistent waitlist/demand management and (mostly) reduced waiting times ~ ~ ~ ~ ~ Control of appointment systems and waiting list management retained by practitioners Promotes continuity of care Enhances coordination of care for consumers requiring multiple services Increases capacity to effectively respond to cultural and linguistic diversity Supports consistent use of service directories and quality service information sharing Supports streamlined, quality consumer information sharing and referral (internal and external) Provides clear and simple referral point for GPs and other referrers Standardisation of data collection, maintenance and analysis practices to support service planning Minimises multiplicity of forms/tools Enables development and use of common forms/tools, for example, risk assessment tools Enhances strategic focus on Service Coordination Consumer Coordination of services Best Practice System Workforce Consumer Coordination of services Best Practice System Workforce Consumer Coordination of services Best Practice System Workforce

70 Service Access Models: A Way Forward Resource Guide for Community Health Services 62 Elements Features Integrated Non Integrated Legend: Applies * Particularly relevant for rostered or allocated activity staffing options Particularly relevant for dedicated staffing option ~ Possibly Integrated: Single Access system - Single discrete access point regardless of the number of sites. Characterised by systematic and consistent practice for all programs/services Parallel Access system - Combination of discrete access points for most services/programs (organisation/site/ LGA/region based) and/or additional discrete program/specialist/ service-specific access point(s). Characterised by integrating mechanisms that support systematic and (mostly) consistent practice for all programs/services Non-Integrated: Multiple access points characterised by variable inconsistent practice per practitioner/discipline/program (historically dominant model ) Single Access system Parallel Access system Supports innovative approaches to systems management Consumer Coordination of services Best Practice System Workforce Consumer Coordination of services Best Practice System Workforce Multiple access points Historically dominant model Enables service access function to be spread according to geographic need ~ Can provide targeted intake function for specific disciplines/programs/consumer groups ~ ~ Autonomy of operation and systems is retained by individual programs/services Increases capacity to streamline workflow practices and delineate task breakdown Eliminates/reduces duplication of tasks Reduces levels of bureaucracy Increases operational efficiencies Reduces budget expenditure due to pooling of funds Supports development of appropriate staffing profiles and human resource deployment Provides clear definition around roles and responsibilities Builds capacity and skill base in relation to IC, INI, knowledge of service system and intake for specific staff Increases workforce cohesion across traditional management and discipline boundaries Supports practitioners with additional time for service delivery Enhances ease of electronic referral deployment and central incoming referral point ~ ~ Challenges Ensuring clarity around access points and referral pathways ~ ~ ~ ~ Ensuring streamlined navigation/intake and referral processes for consumers and service providers Determining when INI is undertaken and by whom Monitoring if/how INI is being undertaken during initial service delivery appointment Supporting consistent application of clear IC, INI and referral policies and processes ~ ~ ~ ~ ~ Supporting consistent application of clear intake policies and processes ~ ~ ~ ~ Ensuring awareness by practitioners of full range of programs/services across organisation and service system Ensuring consistent response to enquiries in order of presentation or priority ~ ~ ~ ~ ~ ~ Balancing demand of telephone and walk in enquiries Maximising practitioner time for direct service delivery (if practitioners undertake IC/INI as part of normal work) Maximising opportunities and capacity for integrated and coordinated care Minimising potential consumer concerns not accessing practitioner at initial contact with organisation Ensuring appropriate client information management processes are in place to ensure: timely and appropriate transfer of records records not being lost between sites or within operational system privacy is maintained and compliance with Health Records Act and Privacy Act Consumer Coordination of services Best Practice System Ensuring received referrals are consistently tracked, acknowledged, monitored and followed up Ensuring facilitated/assisted referrals are consistently offered and provided according to consumer preference Workforce

71 Service Access Models: A Way Forward Resource Guide for Community Health Services 63 Elements Features Integrated Non Integrated Legend: Applies * Particularly relevant for rostered or allocated activity staffing options Particularly relevant for dedicated staffing option ~ Possibly Integrated: Single Access system - Single discrete access point regardless of the number of sites. Characterised by systematic and consistent practice for all programs/services Parallel Access system - Combination of discrete access points for most services/programs (organisation/site/ LGA/region based) and/or additional discrete program/specialist/ service-specific access point(s). Characterised by integrating mechanisms that support systematic and (mostly) consistent practice for all programs/services Non-Integrated: Multiple access points characterised by variable inconsistent practice per practitioner/discipline/program (historically dominant model ) Single Access system Consumer Coordination of services Best Practice System Workforce Parallel Access system Consumer Coordination of services Best Practice System Workforce Multiple access points Historically dominant model Tracking unmet need and identifying gaps in service provision Maximising operational efficiencies Potential fragmentation of forms/tools usage, data collection/waiting list management Potential for phone messages being lost in system Potentially significant change management process Reallocation of fiscal and human resources Potential reconfiguration of office accommodation Potential requirement for infrastructure upgrades (telecommunication systems, IT, software, etc.) Providing an holistic service access approach Perpetuation of silo operation Ensuring application of streamlined and consistent workflow practice Intensive use of resources, duplication of screening and intake resources ~ ~ Maintaining management commitment and enthusiasm to facilitate sustained change Managing workforce responses to sustained change, including maximising value of and supporting staff champions Managing potentially negative perception by practitioners re: need for improvement to current approach loss of control over screening, scheduling and/or waitlist management providing transparency around appointment availability Managing recruitment and capacity building of appropriate staff Enhancing job variety and satisfaction, and retention of appropriate staff Clarification and delineation between reception and dedicated access system staff roles and responsibilities Resourcing of appropriate staff for backfill Workforce impact from balancing constant, multiple demands, competing priorities and crisis events Ensuring completion of consumer follow up while meeting competing direct service delivery demands * * * * * * Reliance on individual disciplines to balance competing demands of access/intake function and service delivery role Implementation Requires analysis of current admin and practitioner time spent on IC/INI to determine appropriate reallocation of human and fiscal resources Distinctions Requires pooling of resources to support improved efficiencies Requires systems to ensure response to enquiries in appropriate order e.g. response to walk in enquiries where services are not located at that site May require system for transport of medical records between sites or electronic access to records (for example, centralised records system) to ensure compliance with Health Records Act and Privacy Act Consumer Coordination of services ~ ~ ~ ~ Can be used to coordinate internal referrals Requires additional approach to ensure consistency and coordination of services between parallel access points Requires effective human resource allocation and monitoring to alleviate workload issues Is well supported by the dedicated staffing option Best Practice System Workforce

72 Service Access Models: A Way Forward Resource Guide for Community Health Services 64 Elements Features Integrated Non Integrated Legend: Applies * Particularly relevant for rostered or allocated activity staffing options Particularly relevant for dedicated staffing option ~ Possibly Integrated: Single Access system - Single discrete access point regardless of the number of sites. Characterised by systematic and consistent practice for all programs/services Parallel Access system - Combination of discrete access points for most services/programs (organisation/site/ LGA/region based) and/or additional discrete program/specialist/ service-specific access point(s). Characterised by integrating mechanisms that support systematic and (mostly) consistent practice for all programs/services Non-Integrated: Multiple access points characterised by variable inconsistent practice per practitioner/discipline/program (historically dominant model ) Viability and Sustainability Risk Management Single Access system Consumer Coordination of services Best Practice System Workforce Parallel Access system Accommodates diversity of program requirements while ensuring consistent practice Consumer Coordination of services Best Practice System Workforce Multiple access points Historically dominant model Can maintain best practice for consumers while accommodating growth in demographics or program provision ~ ~ ~ ~ Supports capacity to provide appropriate service at most appropriate point in consumer journey ~ ~ ~ ~ Maximises embedding of Service Coordination across the organisation Improves efficiencies and reduces number of hours previously spent on IC and INI Allows for manageable level of equipment and staffing Is supported by appropriate resourcing model that can respond to changes in growth or program mix Supports capacity to sustain or improve service levels Increases capacity to identify unmet need and advocate for/allocate appropriate resources accordingly Viability of maintaining multiple access points - operational efficiencies, resource utilisation and reallocation etc Encourages development of documented access system policies, practices and guidelines that address: Clinical factors Non clinical factors (program functions) OH&S factors, for example, crisis or critical incident management Supports development of clearly articulated performance indicators, including policies dealing with breaches in protocols and practice Allows for clear identification of potential risks to consumers Allows for clear identification of potential risks to organisation Supports identification of levels of threat posed to service provision and range of options for dealing with risk to organisation, for example, of service interruptions Uses clearly defined, evidence-based risk identification tools that are appropriate and available for identifying the clinical and psychosocial factors for a range of consumer needs, disciplines and services Ensures identification and resolution to practice issues, guided by appropriate practitioners clinical and professional expertise and organisation policies Supports systematic addressing of additional risk factors relating to: Information management IT systems Communications systems Client records Security management Public liability Internal and external emergencies More easily incorporates systematic consumer complaints and feedback mechanisms around service access and response Ensures periodic review, understanding and adherence to existing control measures, for example, management of crisis presentations ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ Incorporates appropriate role statements and staff profiles to ensure that all staff have responsibility for embedding Service Coordination, and competent staff are employed with appropriate skills to match responsibilities Consumer Coordination of services ~ ~ ~ ~ Best Practice System Workforce

73 Service Access Models: A Way Forward Resource Guide for Community Health Services 65 Elements Features Integrated Non Integrated Legend: Applies * Particularly relevant for rostered or allocated activity staffing options Particularly relevant for dedicated staffing option ~ Possibly Integrated: Single Access system - Single discrete access point regardless of the number of sites. Characterised by systematic and consistent practice for all programs/services Parallel Access system - Combination of discrete access points for most services/programs (organisation/site/ LGA/region based) and/or additional discrete program/specialist/ service-specific access point(s). Characterised by integrating mechanisms that support systematic and (mostly) consistent practice for all programs/services Non-Integrated: Multiple access points characterised by variable inconsistent practice per practitioner/discipline/program (historically dominant model ) Risk Management (cont d) Addresses human resource issues around: Task breakdown, workflow and role delineation Qualifications Recruitment Retention Training Backfill Unplanned/extended leave Job variety, satisfaction and stress management Single Access system Consumer Coordination of services Best Practice System Workforce Parallel Access system Consumer Coordination of services Best Practice System Workforce Supports appropriate workforce development Multiple access points Historically dominant model Reduces direct service delivery time if practitioner undertakes IC and INI during service delivery time * * * * * * * * Risk of enquiries not being followed up/completed if that needs to be completed in service delivery time Increases risk of INI or other inappropriate activity being undertaken by reception/unqualified staff Increases risk of consumer moving from IC directly into service-specific assessment, and INI not being delineated or undertaken (beyond identification of presenting issue) Increases risk of staff burnout Consumer Coordination of services Best Practice System ~ ~ ~ ~ Increases risk of referrals being lost in the system ~ ~ ~ Increases risk of consumers not being seen in order of presentation or priority Perpetuates silo operation and lack of integrated care Limits capacity to identify service gaps ~ ~ Workforce Diagram A4.1 Collated strengths and challenges of various models Strengths Challenges Integrated Single Access Point Integrated Parallel Access Points Non Integrated

74 Service Access Models: A Way Forward Resource Guide for Community Health Services 66 Appendix 5 Staffing options comparative chart Description Composition Skill base Benefits Challenges Dedicated Staff specifically allocated to undertake service access activity on behalf of the organisation, as their primary role. Incorporates a global approach to consumer needs identification. Discrete teams/individual Qualified health/welfare professional (practitioners), generally with significant experience Supports a holistic approach to service delivery Staff focused and targeted at core processes Enhances opportunities for identification of broad consumer needs and prioritisation of access early in contact Supports greatest consistency of response, supported navigation and assisted referrals, comprehensive follow-up of enquiries and managing waiting lists etc. Provides high quality service response by practitioners with significant breadth of experience. Provides an ongoing contact (key worker) for consumers and service provider referrers while awaiting direct service provision Provides a consistent point of contact for GPs and other service providers Provides specific staff with role of remaining up-to-date with service system changes, building relationships with referrers and contributing to greater systems integration Builds organisation capacity through dedicated staff sharing service system knowledge with colleagues Provides opportunities to provide brief service specific interventions at INI Provides opportunities to provide health promotion interventions at INI Can build capacity and skill base in relation to IC, INI, knowledge of service system and intake for specific staff Provides opportunity for greater clarity and delineation around roles and responsibilities Can be provided by a number of part-time staff Structure allows for clear staff accountability, supervision, support and management Structure supports dedicated staff time being allocated to consulting with teams, documenting processes and guidelines and ensuring consistency Expanded role can contribute to building skill base, job satisfaction and retention Service Coordination knowledge and expertise is focussed on small number of staff Requires strategies to ensure broader staff ownership of, and responsibility for, Service Coordination and understanding of the broader service system Requires reallocation of resources (for example, pooling) and specific management Potential difficulties in attracting and retaining practitioners with significant breadth of experience and skill base Absence of pre and post-graduate education and placement opportunities for dedicated role Challenge of ensuring adequate funding to attract and retain suitable practitioners Ensuring adequate numbers of appropriately skilled staff are available to provide backfill and leave cover Ensuring adequate funding for provide backfill and leave cover Potential for dedicated staff burnout due to intensity, demands of the role and reduced job satisfaction Perceived risk of dilution of professional skills brought to the role Risk of higher staff turnover due to lack of diversity in role and perceived de-skilling of professional skills Service can reduce/collapse when worker leaves, due to lack of redundancy/backup Loss of skills and knowledge when staff leave Note: Workforce issues are significantly minimised if positions incorporate an adequate mix of activity or are part-time. Non-practitioner usually highly skilled and trained and backed up with decision support tools and practitioner support Increases time for direct service delivery by health professionals Staff focused and targeted at core processes Encourages ongoing capacity building and professional development for non-practitioners Supports consistency of response, supported navigation and assisted referrals, comprehensive follow-up of enquiries and managing waiting lists, etc. Provides an ongoing contact (key worker) for consumers and service provider referrers while awaiting direct service provision Provides a consistent point of contact for GPs and other service providers Supports specific staff to remain up-to-date with service system changes, build relationships with referrers and contribute to greater systems integration Can build organisation capacity through dedicated staff sharing service system knowledge with colleagues Builds capacity and skill base in relation to IC, limited needs identification, knowledge of service system and intake for specific nonpractitioner staff Provides opportunity for greater clarity and delineation around roles and responsibilities Requires lower salary rates than if using practitioners Can be provided by a number of part-time staff Can draw significant number of job applicants to select from Structure allows for clear staff accountability, supervision, support and management Structure supports dedicated staff time being allocated to consulting with teams, documenting processes and guidelines and ensuring consistency Expanded role can contribute to building skill base, job satisfaction and retention Requires strategies to ensure broader staff ownership of, and responsibility for, Service Coordination and understanding of the broader service system Requires reallocation of resources (for example, pooling) and specific management Requires clear delineation, such as of limits of role, identification of presenting need but not broad INI Increases clinical risks if non practitioners undertake broad INI, risk screening, brief interventions etc. Requires intensive training, back-up and supervision around screening, risk identification, agreed interventions and use of screening tools Requires significant decision support tools and systems to ensure practitioner availability for back-up Highlights the importance of appropriate screening tools May require completion of broad INI/screening to also be built into practitioner role Monitoring of practitioner follow-up of INI may be required to ensure quality and consistency May reduce capacity for early needs identification and interventions May limit opportunities to provide brief service specific interventions at access point May limit opportunities to provide health promotion interventions at access point Potential for dedicated staff burnout due to intensity and demands of the role Risk of higher staff turnover due to lack of diversity and demands of the role

75 Service Access Models: A Way Forward Resource Guide for Community Health Services 67 Description Composition Skill base Benefits Challenges Rostered Staff rostered to undertake service access role on behalf of organisation for specific timeframes, in addition to their normal service delivery role. Incorporates a global approach to consumer needs identification. From any discipline, service or program Qualified practitioner Supports a holistic approach to service delivery and holistic emphasis by all workers May enhance opportunities for identification of broad consumer needs and prioritisation of access early in contact, if staff are significantly informed and aware of available alternatives Supports development of common organisational culture Provides opportunity to share activity Facilitates greater understanding of the service system across workforce Assists all staff involved with remaining up-to-date with service system changes, building relationships with referrers and contributing to greater systems integration Can build staff capacity and skill base in relation to IC, INI, knowledge of service system and intake Provides diversity of role and reduces burnout risk May provide opportunities to provide brief service specific interventions at INI May provide opportunities to provide health promotion interventions at INI Inbuilt redundancy back-up if shadow roster is incorporated Mix of workers allows for more consumer choice re: interaction with worker, for example, can ring back at different time to speak to alternate worker Increased peer support Better coverage over break periods Note: Shadow roster pool of staff trained in service access role who alternate between active/shadow roster per month or fortnightly periods. Shadow staff available to substitute for active worker in the event of unplanned illness or emergency. Requires: organisational prioritisation of service access response ahead of other service delivery coordinator role to ensure system development and consistent practice etc (for example: 0.4 EFT for a small system with 20 staff) Reduces capacity for direct service delivery Balancing direct service work with service access role - may not be viewed as important as direct service delivery Ensuring equity of contribution by all staff/teams Risk of staff having limited understanding of role responsibilities, for example only to take calls Ensuring that all staff are supported to undertake breadth of role and maintain knowledge of service system High risk of inconsistent practice Program/service specific health professionals may focus on their discipline rather than a holistic approach Risk of service delivery time being used to complete/follow-up enquiries Risk of follow-up not being completed May be seen as taking away from core role of service delivery Structure does not allow for clear staff accountability, supervision, support and management around access role Structure does not support time or role being allocated to consult with teams and document processes and guidelines to ensure consistency Ensuring appropriate use of shadow roster

76 Service Access Models: A Way Forward Resource Guide for Community Health Services 68 Description Composition Skill base Benefits Challenges Allocated activity Staff within a discipline/ service/program/team undertake service access activity on behalf of that team, as a permanent component of their role Primary focus is on intake processes. For example, allied health assistant (AHA) responds to access queries on behalf of Allied Health Team or Chronic Disease Self Management Program Discipline/team service/program/ specific Non-practitioner usually highly skilled and trained (eg. AHA), with decision support tools and practitioner back up Increases time for direct service delivery by health professionals Staff focused and targeted at core processes Specialised knowledge of discipline/team/service/program is used Encourages ongoing capacity building and professional development for non-practitioners May provide an ongoing contact for consumers and service provider referrers while awaiting direct service provision within that team/service only Provides a consistent point of contact for GPs and other service providers for that discipline/service Builds capacity and skill base in relation to IC, limited needs identification, knowledge of service system and intake for specific nonpractitioner staff Provides potential to share activity between a number of staff Risk of perpetuating service silos and non-integrated care Risk of worker focusing on a particular discipline rather than a holistic consumer-centred approach Requires clear delineation re limits of role, for example, identification of presenting need for that discipline/team only but not broad INI Increases clinical risks if non practitioners undertake broad INI, risk screening, brief interventions etc. Requires training, back-up and supervision re screening, risk identification, agreed interventions and use of screening tools for that discipline/team only Requires decision support tools and system to ensure practitioner availability for back-up Highlights the importance of appropriate screening tools May require completion of broad INI/screening to also be built into practitioner role Monitoring of practitioner follow-up of INI may be required to ensure quality and consistency May reduce capacity for early needs identification and interventions beyond presenting need May limit opportunities to provide brief service specific interventions at access point May limit opportunities to provide health promotion interventions at access point Potential for intake staff burnout due to intensity and demands of the role and reduced job satisfaction Risks of higher staff turnover due to lack of diversity in role and perceived deskilling of professional skills Qualified practitioner Specialised knowledge of discipline/service/program is used Builds capacity and skill base in relation to IC, INI, knowledge of service system and intake for specific staff May provide an ongoing contact for consumers and service provider referrers (for example, key worker) while awaiting direct service provision within that discipline/service only Provides a consistent point of contact for GPs and other service providers for that discipline/service only Supports a holistic approach to service delivery within discipline/ team/service/program May enhance opportunities for identification of broad consumer needs and prioritisation of access early in contact, if staff are significantly informed and aware of available alternatives May provide opportunities to provide brief service specific interventions at INI May provide opportunities to provide health promotion interventions at INI Provides diversity and reduces burnout risk Provides potential to share activity between a number of staff Risk of perpetuating service silos and non-integrated care May be seen as detracting from core role of service delivery Risk of discipline/service specific practitioners focusing on their particular discipline rather than a holistic approach Reduces direct service delivery capacity May reduce capacity for early needs identification and interventions beyond presenting need May limit opportunities to provide brief service-specific interventions at access point May limit opportunities to provide health promotion interventions at access point May provide limited capacity to follow up enquiries, manage waiting lists etc.

77 Service Access Models: A Way Forward Resource Guide for Community Health Services 69 Description Composition Skill base Benefits Challenges Individual role activity Individual staff undertake service access activity for their discipline/role only, as a permanent component of their role. Primary focus is on intake processes. Staffing by individual role activity has been the dominant approach; however, this can result in duplication, inconsistent practice, inefficient use of resources and nonuniform responses to consumer needs. Individual/role specific Qualified practitioner Specialised knowledge of discipline/role is used May build capacity and skill base in relation to IC, INI, knowledge of service system and intake May provide an ongoing contact for consumers and service provider referrers (for example, key worker) while awaiting direct service provision within that discipline/service only Provides a consistent point of contact for GPs and other service providers for that discipline/service only May support a holistic approach to service delivery if staff are significantly informed and aware of broader issues and options May enhance opportunities for identification of broad consumer needs and prioritisation of access early in contact, if staff are significantly informed and aware of available alternatives and using consistent prioritisation tools etc. May provide opportunities to provide brief service specific interventions at INI May provide opportunities to provide health promotion interventions at INI Provides diversity and reduces burnout risk Significant challenge to ensure that all staff are supported to undertake breadth of role and maintain knowledge of service system Risk of staff having limited understanding of what role is responsible for, for example, only to respond to enquiries for their own discipline Limits capacity for consumers to receive broad INI and response to complex needs Limits capacity for consumers to be informed of broader service system options Consumer and referrer have to navigate the system. It is unclear who to refer to whom Perpetuates culture of practitioners focusing on their particular discipline rather than a holistic consumer-centred approach Perpetuates service silos and non-integrated care High risk of enquiries not being responded to in a timely fashion Increased likelihood of enquiries being lost in the system High risk of inconsistent practice Challenge of balancing direct service work with service access role Consumers/referrers needing to leave messages as practitioners not available to respond to enquiries while undertaking direct service delivery May not be viewed as important as direct service delivery Reduces direct service delivery capacity - high use of service delivery time to follow up/complete enquiries Minimal incentive for staff to enquire beyond discipline-specific enquiry Risk of follow-up not being completed Limits capacity for early needs identification and interventions beyond presenting need Limits capacity to provide brief service specific interventions at access point beyond presenting need Limits opportunities to provide health promotion interventions at access point beyond presenting need Significant duplication of effort and inefficient use of resources Structure does not allow for clear staff accountability, supervision, support and management around access role Structure does not support time or role being allocated to consult with teams and document processes and guidelines to ensure consistency across organisation Significant duplication of effort and inefficient use of resources Quality of service can reduce/collapse when worker leaves, due to lack of redundancy/back-up Risk of messages being unattended to for lengthy periods if worker takes leave, due to inadequate leave/cover provisions Loss of skills and knowledge when staff leave Reliance on reception staff for initial assessment and to determine which discipline Reduced capacity to provide privacy for clients at reception Multiple permutations ranging from individual to discipline responses increase complexity Less accountability regarding quality

78 Service Access Models: A Way Forward Resource Guide for Community Health Services 70 Appendix 6 Suggested change management process 54 Step 1 Step 2 Step 3 Step 4 Step 5 Step 6 Change management steps Elements Examples of key tasks Scope project Endorsement and signoff by all key stakeholders Project establishment Map current service access processes Identify and analyse findings Conceptualise new model Consider context, such as Community Health Program vision and future directions, HACC future directions, Care in Your Community, PCP strategy. Establish principles, for example, link to organisation vision and strategic directions, consumerfocused approach, minimise duplication, maximise effectiveness and efficiency. Determine what is do-able. Consider adopting a phased or evolutionary process where acrossthe-board change is not achievable or desirable. Develop a documented strategic work plan with well developed timelines, which are essentially adhered to, as practicable. Develop key milestones and conduct a regular review of progress against the milestones and objectives outlined in project work plan. Clarity and mutual agreement around givens and non-negotiables. Consider clinical issues and what services/functions are in or out of scope. Endorsement of project scope and work plan by key stakeholders. Determine resource provision appropriate to the scope of the project Convene a project working group, with representation from key areas with delegated authority to provide input and feedback from the areas they represent. Appoint a project leader/champion to facilitate the process. Establish reporting structures and decision making authorities. Finalise service access model objectives. For example: achievement of a centralised, integrated booking system for all client appointments protocols to facilitate client access to urgent appointments active and assisted referrals to external and internal services protocols to facilitate management of clients in crisis situations. Determine model selection criteria Develop a communication strategy that includes internal and external stakeholders (internal services, clients, broader community, other service providers, staff). Familiarise management and staff with Victorian Service Coordination Practice Manual (incorporating Good Practice Guide for Practitioners and Continuous Improvement Framework) and PCP Service Coordination PPPS. Conduct a review of existing structures, processes, time allocation and impact evaluation. Conduct a detailed mapping process to assist in highlighting current efficiencies and inefficiencies. Analyse findings from the review and mapping process, identify gaps, time utilisation issues, the nature of the issues (whether they are internal or external system issues). This will begin to clarify the type of service access model that would best suit the organisation. This is also important for considering and confirming what will be in or out of scope. Conduct a conceptualisation/brainstorming session with key stakeholders to dream about what you want the service access system to look like dare to dream the ideal. Analyse the options around what is achievable and what is not. Scope project Establish principles Determine key stakeholders Develop work plan Identify key milestones Determine timelines Obtain endorsement and sign off by board/executive, senior management, PCP, as appropriate Seek and secure resources to conduct project Determine assistance and support the PCP may be able to provide Form working group Finalise project scope, objectives and processes Develop criteria for model selection Develop and implement communication strategy Establish reporting requirements Develop agreed definitions of terminology to guide the process and assist staff Meet with referral partners to keep them updated on changes in your organisation and consider collaborating on change management strategies for implementation in other organisations Map current processes related to IC, INI, referral (and potentially assessment and care planning) in a flow chart for each discipline Identify how consumers are assisted to identify their broad needs and navigate the service system Collect key information on these processes, for example, clients, staff hours, etc. Prepare snapshot report on current service access processes Benchmark processes and findings against Desirable outcomes (Part 2), Service access models comparative chart (Part 3) and other CHSs if relevant Analyse information collected in Step 4 Identify what is working well Identify weaknesses and areas for improvement Audit current practice against the Victorian Service Coordination Continuous Improvement Framework Conduct a conceptualisation/ brainstorming session Decide what is and is not achievable in light of reviewing, brainstorming and impact measuring processes Determine what you want the model to achieve. Consider what functions can be centralised and integrated as well as potential structural design function and resourcing (financial, infrastructure, staffing) 54 Adapted from documents developed by Effective Change Pty Ltd, Inner East PCP and various other sources, including CHSs

79 Service Access Models: A Way Forward Resource Guide for Community Health Services 71 Step 7 Step 8 Step 9 Change management steps Elements Examples of key tasks Step 10 Step 11 Step 12 Select new service access model Determine precise role and function of service access model Develop new service access system Develop implementation plan Implement new service access system Review Identify suitable models. Select preferred model. Conduct a risk assessment (and/or a health impact assessment*) of all/preferred model against factors affecting consumers, organisation, referral partners, etc. Determine the role, function and activities that the selected service access model is to perform Confirm service access model capacity to meet the role and functions Develop the new service access system Develop appropriate policies, procedures and forms Consider infrastructure, including telecommunication systems, office configuration appropriate to provide privacy for clients and IM/IT, Internet access, service directories, etc. Where viable, upgrade IT, otherwise use existing software to support new system Develop a staffing strategy Develop a business plan if/as required. Conduct a cost analysis for implementation for inclusion in the business plan Develop an implementation plan Understand and communicate transitional aspects of phased-in changes Manage transition between old and new systems Establish phase of new service access system Activate change management strategy Commence marketing strategy Ongoing monitoring, evaluation and continuous improvement of service access system Plan to undertake an evaluation/impact analysis of the service access system once all services are on board, including survey of clients, staff, external organisations, service providers. Incorporate any necessary changes following the evaluation/impact analysis into the operation of the service access system. Identify and scope potential service access model options Conduct risk assessment (and/or health impact assessment) of each/preferred model option Select an appropriate service access model exercising an educated leap of faith in choosing one model over another Decide what role and functions the model is to perform Conduct an analysis of the chosen service access model against the criteria for the model selection to gauge its capacity to fulfil what is required Develop and streamline the preferred service access system including: policy and procedures client pathway and document trail eligibility and priority of access criteria service guides and discipline/service specific risk assessment tools position descriptions infrastructure client records and registration processes waitlist/demand management appointment scheduling data collection. Develop implementation plan which includes: staged implementation staffing strategy and role clarification infrastructure support information and education strategy change management strategy marketing strategy monitoring and evaluation process. Employ or redeploy staff Work with teams to develop: service guides risk assessment and prioritisation tools waiting list system appointment system. Market new service access system provide education to staff, clients, community, external organisations, GPs. Develop measurements to ascertain the access model s effectiveness and efficiency. For example: breadth of needs identification practitioner time for direct client service delivery waiting list management successful referral to other organisations navigation through service system. Conduct an impact/outcomes analysis that captures impact/outcomes upon (for example): consumers staff organisation services/programs service access practices other organisations demand management records management for example, health impact assessment*) Implement any necessary changes identified in the evaluation process. *Health impact assessment A combination of procedures, methods and tools by which a policy, program or project may be assessed and judged for its potential, and often unanticipated, effects on the health of the population Mahoney,M.,et al, Health Impact Assessment Research Unit, Deakin University (2005)

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