Case Management: A Multidisciplinary Approach

Transcription

1 Case Management: A Multidisciplinary Approach C A L V A R Y H E A L T H C A R E S Y D N E Y T R A N S I T I O N A L A G E D C A R E S E R V I C E J U N E 8 TH K A T E C O N N O R

2 Calvary Transitional Aged Care Service St George Area- Sydney Started September packages

3 Calvary Transitional Aged Care Service 41 community packages Team includes Allied Health: Physiotherapy, Occupational Therapy, Social Work, Dietetics, Speech Pathology and Allied Health Assistants Nursing Medical Administrative Contracted support services provider

4 Presentation Outline Evidence Problems A Case Management Model Case Management Tools Evaluation Where to from here? References

5 Evidence A systematic review of different models of home and community care services for older people (Low et al, 2011) Improves function Aspects of medication management Increases use of services Reduces residential placement Decreases hospital admissions

6 Evidence The best practices in Case Management requires organisational arrangements to support service delivery, staff who have been trained for the approach and its application to the particular practice setting and strategies to ensure that the organization can be responsive to evidence from practice and advocate for systemic and policy change to support service delivery (The Case Management Society of Australia, 2012)

7 Problems Initially only Nursing and Social Work provided case management services Uneven distribution of workload Decreased job satisfaction Loss clinical skills Difficulty covering leave periods

8 Problems Inconsistencies in the provision of case management Assessment process Frequency of visits Discharge planning Uncertainty as to the role of the case manager Undefined boundaries between case management and discipline specific roles- give example

9 A Multidisciplinary Approach Change to Multidisciplinary approach Nursing, Social Work, Physiotherapy, Occupational Therapy and Dietetics Match clients with appropriate discipline Expansion of role Fosters a holistic approach to care Assists with team cohesion

10 A Case Management Model Development of a Case Management model Evidence based Good Practice Guide for HACC Funded Case Management Projects NSW Health Clinical Services Redesign Program: Case Management ADAPT Case Management Model Clearly defined stages of case management Assessment Planning and Linking Monitoring and Review Closure Follow Up

11 A Case Management Model Assessment Case Managers Initial Assessment Tool Links with Multidisciplinary Assessments Covered immediate concerns post discharge home Planning and Linking Development of a person centred, goal focused Care Plan Liaison (referring hospital, medical specialists, service providers, ) Implementation of home support services Discharge planning

12 Case Management Model Monitoring and Review Minimum weekly contact with client/carers Case Conferencing Monitoring and review against the care plan Discharge Planning Closure Handover Discharge of file Follow Up 1 week 3 month post TACS follow up phone call

13 Case Management Tools Case Management Policy Procedure Case Management Model- steps Allocation of Case Management Guidelines for service provision Case Management Initial Assessment Tool Case Managers Checklist

14 How do we know it is working? Key Case management components- before and after file audit Increase in discharge planning 62%-92% Consistence of at least weekly contact 67%-92% Discharge planning average length of stay Average length stay decrease 10 days TACS Staff Survey Timely and effective communication increase 43% (2010) to 87% 2012 responding most of the time

15 Where to from here?? Review of Care Planning and Case Management processes against the new Transition Care Program Quality Standards and NSW MoH TACP Protocols and Procedures Manual (once released

16 References NSW Health Clinical Services Redesign Program. (2007). Case Management. NSW Health, October (Retrieved from NSW Department of Ageing, Disability and Home Care. (2006). Guidelines for the Operation of HACC Funded Case Management Projects. DADHC, August (Retrieved from: data/assets/file/0018/228204/goodpracticeguidefinal. pdf) ADAHPT. ADAHPT Case Management Model. NSW Health. (retrieved from: Case Management Society of Australia. What is Case Management?. Case Management Society of Australia, (Retrieved from: Cooper, B. and Yarmo, R. (2006). National Case Management Standards in Australia - purpose, process and potential impact. Australian Health Review; 30(1): Low, L-F. Brodaty, H. (2011). A systematic review of different models of home and community care services for older people. BMC Health Services Research; 11:93.