Northern Mallee Primary Care Partnership REFERRAL GUIDELINES & PROTOCOLS July 2012 Sunraysia Community Health Services Robinvale District Health Services Mildura Rural City Council Bendigo Health Services 1 P age
NMPCP ICDM/SC Network Goal 2 Referrals Working Party Members Rebecca McDonald NMPCP Linda Henderson SCHS Jackie Reddick SCHS Lisa Taggert RDHS Louise Goullet MRCC Joy Bosworth Bendigo Health Services Janeece Madigan SCHS The Northern Mallee Referral Guideline and Protocol booklet is an agreed and documented resource for the use of employees of primary health and community support services. To achieve a common service system, agencies are required to integrate locally agreed common processes and protocols to their practice. This is designed to streamline and simplify referral practices to the benefit of consumers and service providers alike. Although many processes, procedures and protocols are common across agencies, each agency needs to develop its own local procedure to interface between the common system and local practice. This guide has been developed in response to an identified need for improved communications and referrals between services at Sunraysia Community Health Services, Robinvale District Health Services, Mildura Rural City Counsel and Bendigo Health Services. The Guide will contain both referenced material from the departmental policy and localised information. It is designed to support service providers to make improved referrals and improve the consumer pathway. The next phase of the guide will be to expand and include all PCP member agencies within the next 12 months. 2 P age
INDEX PAGE Introduction Pg 4 Service Coordination Pg 5 Initial Contact Pg 6 Initial Needs Identification Pg 7 Assessment Pg 8 Care Planning Pg 9 Referrals Pg 11 Resources & Tools to support Service Coordination Pg 14 ICDM/SC Network Pg 15 References Pg 16 3 P age
INTRODUCTION Primary Care Partnerships The state government funds 30 Primary care Partnerships (PCPs) to improve access to services and continuity of care for people through improved service coordination, as well as chronic disease prevention, integrated health promotion, and partnership development. Primary Care Partnerships (PCPs) are made up of a diverse range of member agencies where organisations actively participate in SC Initiatives, (Identification, Planning, Implementation and Resources) to build stronger relationships to support and enhance primary care services in our region for the benefit of the consumers and the wider service sector. Our goal is to improve communication between PCP member agencies in the Northern Mallee region, in relation to patient referral and information sharing through an agreed streamlined and consistent approach to referral acknowledgement, content and feedback for at least 4 participating member agencies with the hope of expanding to all PCP Member Agencies. 4 P age
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, health promotion and improved health and care outcomes. The operational elements of Service Coordination, as described in the Better Access to Services Policy and Operational Framework (DHS, 2001), are Initial Contact, Initial Needs Identification, Assessment and Care Planning. Service Coordination enables organisations to remain independent of each other, while working in a cohesive and coordinated way to give consumers a seamless and integrated response. CRITERION 3 CRITERION 6 CRITERION 4 CRITERION 5 5 P age
INITIAL CONTACT Criterion 3 Initial contact is the first point of contact for a consumer with the service system. It is an important function of every service provider and usually includes the provision of accurate, comprehensive service information and facilitated access to Initial Needs Identification. 6 P age
INITIAL NEEDS IDENTIFICATION Criterion 4 Initial Needs Identification is a brief, broad screening process to uncover underlying and presenting issues. Initial needs identification canvasses the consumer s needs as well as opportunities for intervention and information provision early in their contact with the service system. The service provider engages in a broad conversation to identify these needs. It is not a diagnostic process, but includes identification of the consumers risk, eligibility and priority for service. Initial needs identification involves a whole of person, consumer centred approach. 7 P age
ASSESSMENT Criterion 5 Assessment is a decision making methodology that collects and interprets relevant information about the consumer. Assessment is not an end in itself, but part of an ongoing process of delivering services. It is an investigative process using professional and interpersonal skills and in depth inquiry to identify relevant issues that will guide a responsive intervention. 8 P age
CARE PLANNING Criterion 6 Care/case planning is a dynamic process that incorporates assessment coordination, care/case management, referral, information exchange, and review, reassessment, monitoring and exiting. Care/case planning involves balancing relative and competing needs and helping consumers make decisions appropriate to their needs, wishes values and circumstances. Care/case planning may occur at an individual provider level, and both within and across agencies. 9 P age
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REFERRALS Referrals are a critical communication tools for service providers but more importantly referrals are the information sharing mechanisms that allow services to be implemented and information communicated for clients. Referrals can occur at any stage of the service coordination cycle. Referral involves the transferring of information about a consumer for the purpose of accessing additional health or welfare services for the client. There are three types of Referrals that exist: Self Referral where the consumer chooses another service themselves. Service providers should support this process by providing contact details of the other service, advice and completing the service coordination tool template if appropriate (Victorian Service Coordination Practice Manual, 2012). Assisted Referral where a service provider makes a referral on behalf of the consumer using the SCTT. This type of referral requires the service provider to obtain consent from the consumer. This is the referral type that clinicians or intake staff would most likely complete. Active or Crisis Referral this situation occurs when the consumer is extremely anxious or in crisis. Further details on the protocols regarding this can be found in the Service Coordination Practice Manual (2012) and in individual organisations policies. The discussion on referrals in this guide is primarily focused on Assisted Referrals. The purpose of the referring a client or consumer to another service may be for further needs identification assessment and or treatment. A referral must involve the consent of the client (in certain emergency situations this may be waived). Referrals come into services using a variety of methods such as fax, post and electronic sources such as Connectingcare and Argus. Timeliness for referrals is essential. This timeliness is not limited to the sending of referrals to and from a service. Rather it infers the need to acknowledge referrals, provide adequate and timely feedback and to follow up referrals where needed. 11 P age
Service Coordination Guidelines Referrals Service Coordination 2012 The Service Provider making a referral explains referral option and processes to the consumer. This may involve: Assisting the consumer to identify their issues and define their needs Practice that is sensitive to cultural, communication, cognitive needs as well as personal safety and risk of violence Sourcing information from relevant service directory, e.g. Human Service Directory, or calling the services directly Explaining waiting times and service limitations Discussing the pros and cons of self referral Offering to make the referral on their behalf (particularly if the consumer finds their options confusing, distressing or frustrating) Facilitating referrals/and or assisting with navigation and negotiation of the service system when appropriate Explaining the use of information for referral and explaining referral options Providing the consumer with information about their rights, including the option of sharing all, or some, information Assisting the consumer to make an informed choice The service provider making a referral: Offers the consumer a copy of the Your information It s private brochure or relevant service provider information, and checks the consumer has understood it Completes the relevant sections of the referral form used, e.g. SCTT Makes an assessment of risks faced by the consumer and/or staff Prioritises the referral as urgent or non urgent The service provider sending a referral is expected to: Send referrals in accordance with privacy requirements Transmit referrals using a secure e referral system, or through secure fax or post Contact the service provider/s receiving the referral, if appropriate, to prioritise the referral, provide additional consumer information or discuss assessment, care/case planning or service delivery options. Use referral templates that support consistent, quality information that meets the needs of the service, e.g. SCTT Send urgent referrals within no more than l working day of obtaining consumer consent the reason why the referral is urgent needs to be specified Send non urgent referrals within no more than 7 working days of obtaining consumer consent Make immediate referrals (for example, over the phone) when consumer is in crisis, or assessed as being at high risk of family violence and follow this up with a more detailed referral, e.g. SCTT 12 P age
The service provider supports the consumer to make a self referral. If they choose to do so, and may support the consumer, by providing: Information, such as service provider contact details Advice and decision making support A copy of the completed referral forms, e.g. SCTT, if appropriate The service provider making a referral monitors the consumer s status until a response to the referral is received and accepted. At this point, both service providers should agree who is responsible for monitoring the consumer if they are placed on a waiting list. If the receiving service provider does not respond within agreed timelines, the sending service provider must check to ensure the referral has been received. The service provider receiving a referral is expected to: Transmit acknowledgement of the referral (service providers may use the SCTT Referral cover sheet and acknowledgement template for this) to the initiating service, stating that the referral has been received and the estimated date of consumer assessment, or the reason why the referral is not proceeding Acknowledge urgent referrals within no more than 2 working days of receipt Acknowledge non urgent referrals within no more than 7 working days of receipt Transmit referral outcome information to the initiating service provider within no more than 14 working days of the consumer being assessed. If the referral is not appropriate, this must be communicated to the referring service by the organization to which the inappropriate referral has been made. 13 P age
Resources and Tools to support Service Coordination How do the Service Coordination Tool Templates support Service Coordination The Service Coordination Tool Templates (SCTT) is a suite of templates developed to facilitate and support Service Coordination. They support standardised collection and recording of initial contact, initial needs identification, referral and care/case planning information. Using SCTT can improve communication between service providers; consistency of information collected from screening and assessment processes, and improves the quality of referrals. This can help services to share relevant information to support better outcomes for consumers. Many program areas have integrated SCTT into their practice guidelines and reporting mechanisms. The templates are not designed as a minimum data set for reporting or as program specific collection tools. SCTT are designed to meet the needs of the many different service types and consumer groups that implement service coordination. To meet the needs of new and existing users, a continuous improvement approach has been adopted to update SCTT. The SCTT 2012 User Guide is available to assist in the use of the templates. The guide provides and introduction and overview of the templates, and supports service providers in completing them. Figure 3: illustrates the alignment of the individual templates with the SCTT with the service coordination elements. 14 P age
ICDM/SC Network The ICDM Working Group has put together this booklet to improve communication between PCP member agencies in the Northern Mallee Region, in relation to patient referral and information sharing. The objective was to develop and implement an agreed streamlined and consistent approach to referral content for participating agencies to ensure effective referrals are being sent. The guide is also useful for agencies when training new staff as this booklet will contain all the information at departmental level but also at a local level. This will enable new staff to know what SCTT Template must be completed in order for a referral to go through to a specific service for the participating agencies. Agencies have identified what their requirements of expectation are in the following SCTT Templates which must be completed for it to be an effective referral. This booklet will be updated and reviewed when requested by member agencies at the ICDM/SC Network. 15 P age
Referral Check Sheet MRCC & SCHS HACC SERVICES Which Tools need to be included for an effective referral Reference 2009 SCTT Templates
Referral Check Sheet ROBINVALE DISTRICT HEALTH SERVICES Which Tools need to be included for an effective referral SERVICE COORDINATION TOOLS HACC HOME PT PODIATRY OT SPEECH DIETETICS PAG SOCIAL COMMUNITY CORE TEMPLATES Confidential Referral Cover Sheet *Consumer Consent to Share Information Consumer Information Summary & Referral Information OPTIONAL TEMPLATES Need for Assistance Living & Caring Arrangements Health Behaviours Health Conditions Psychosocial Family & Social Network SUPPLEMENTARY TEMPLATES Functional Assessment Summary Palliative Care Supplementary information NURSING THERAPY WORK NURSING Reference 2009 SCTT Templates
Referral Check Sheet MALLEE TRACK HEALTH & COMMUNITY SERVICE Which Tools need to be included for an effective referral SERVICE COORDINATION TOOLS HACC HOME PT PODIATRY OT SPEECH DIETETICS PAG SOCIAL COMMUNITY CORE TEMPLATES Confidential Referral Cover Sheet *Consumer Consent to Share Information Consumer Information Summary & Referral Information OPTIONAL TEMPLATES Need for Assistance Living & Caring Arrangements Health Behaviours Health Conditions Psychosocial Family & Social Network SUPPLEMENTARY TEMPLATES Functional Assessment Summary Palliative Care Supplementary information NURSING THERAPY WORK NURSING Reference 2009 SCTT Templates
Referral Check Sheet SUNASSIST Which Tools need to be included for an effective referral SERVICE COORDINATION TOOLS CORE TEMPLATES Confidential Referral Cover Sheet TRANSPORT ESCORTED SHOPPING ESCORTED MEDICAL SOCIAL OUTINGS PHONE ASSIST FRIENDLY VISITS *Consumer Consent to Share Information Consumer Information Summary & Referral Information OPTIONAL TEMPLATES Need for Assistance Living & Caring Arrangements Health Behaviours Health Conditions Psychosocial Family & Social Network SUPPLEMENTARY TEMPLATES Functional Assessment Summary Palliative Care Supplementary information Reference 2009 SCTT Templates
Referral Check Sheet Mildura Aboriginal Cooporation Which Tools need to be included for an effective referral SERVICE COORDINATION TOOLS HACC Housing Support Home based care Family Services Youth Services Bringing them Home AHPACC AOD/SEW Healthy for Life Tobacco Action Early Years Clinical Service GP CORE TEMPLATES Confidential Referral Cover Sheet *Consumer Consent to Share Information Consumer Information Summary & Referral Information OPTIONAL TEMPLATES Need for Assistance Living & Caring Arrangements Health Behaviours Health Conditions Psychosocial Family & Social Network SUPPLEMENTARY TEMPLATES Functional Assessment Summary Palliative Care Supplementary information Reference 2009 SCTT Templates
Referral Check Sheet MILDURA BASE HOSPITAL Which Tools need to be included for an effective referral SERVICE COORDINATION TOOLS HARP CORE TEMPLATES Confidential Referral Cover Sheet *Consumer Consent to Share Information Consumer Information Summary & Referral Information OPTIONAL TEMPLATES Need for Assistance Living & Caring Arrangements Health Behaviours Health Conditions Psychosocial Family & Social Network SUPPLEMENTARY TEMPLATES Functional Assessment Summary Palliative Care Supplementary information Reference 2009 SCTT Templates
Referral Check Sheet BENDIGO HEALTH SERVICES Which Tools need to be included for an effective referral SERVICE COORDINATION TOOLS CORE TEMPLATES Confidential Referral Cover Sheet *Consumer Consent to Share Information Consumer Information Summary & Referral Information OPTIONAL TEMPLATES Need for Assistance Living & Caring Arrangements Health Behaviours Health Conditions Psychosocial Family & Social Network SUPPLEMENTARY TEMPLATES Functional Assessment Summary Palliative Care Supplementary information CASE MANAGEMENT CARER SUPPORT SERVICES Reference 2009 SCTT Templates
Referral Check Sheet SUNRAYSIA ETHNIC COMMUNITY COUNCIL Which Tools need to be included for an effective referral SERVICE COORDINATION TOOLS HACC CORE TEMPLATES Confidential Referral Cover Sheet *Consumer Consent to Share Information Consumer Information Summary & Referral Information OPTIONAL TEMPLATES Need for Assistance Living & Caring Arrangements Health Behaviours Health Conditions Psychosocial Family & Social Network SUPPLEMENTARY TEMPLATES Functional Assessment Summary Palliative Care Supplementary information Reference 2009 SCTT Templates
REFERENCES Resources to Support Service Coordination 1. Victorian Service Coordination Practice Manual 2. Good Practice Guide A3 Poster 3. Continuous Improvement Framework 4. Service Coordination Tool Templates (SCTT) These publications are available at the Department of Health PCP web page: www.health.vic.gov.au/pcps/coordination In addition to these four Publications there is an extensive range of supporting resources and tools to support the practice of Service Coordination. A full list of these resources can be found in: Section 5 of the Victorian Service Coordination Practice Manual 16 P age