echuca regional health hospital admissions risk program – harp martin pugh april 2013
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Echuca Regional HealthEchuca Regional Health
Hospital Admissions Risk Program Hospital Admissions Risk Program – HARP– HARP
Martin PughMartin PughApril 2013April 2013
Background Background
HARP was started in Victoria in the late 1990s as a response to increased demand on acute wards.
Initially it was only for Metropolitan areas but from 2007 onwards rural areas also began to trial HARP.
WhyWhy
HARP helps people with health and social needs many of whom have a chronic illness and who frequently use hospitals or who are at risk of hospital admissions
Key Objectives of HARPKey Objectives of HARPImprove client outcomesProvide integrated and seamless care
within and across hospital and community sectors
Reduce avoidable hospital admissions and emergency department presentations
Ensure equitable access to health care
Eligibility CriteriaEligibility CriteriaHARP works with people of all ages
Clients have had to have had at least one unplanned admission in the last 12 months or at risk of admission with no other appropriate services to help
How it worksHow it works
All HARP clients have a Care Co-ordinator.
Some clients need significant input from the Care Co-ordinator whilst others are referred on to more appropriate services
How it WorksHow it Works
HARP clients receive client centred care with a Care Plan based around individual needs .
These needs include physical and mental health, psycho-social and environmental needs
The Client JourneyThe Client Journey
Like clients from other Health Independence Programs HARP clients go down the following journey
The Client JourneyThe Client JourneyAccessInitial Needs IdentificationAssessmentClient ConsentCare Planning and ImplementationMonitoring and reviewTransition and exit
Echuca HARPEchuca HARP
Initially HARP-BCOP - this program was a pilot project from 2007
In 2010 it received ongoing funding and became a program helping people of all ages
Echuca HARP Echuca HARP
Is a multi-disciplinary team consisting of Social Workers, a nurse and an Occupational Therapist.
All are employed as Care Co-ordinators but utilise their individual disciplines to improve client care
Echuca HARPEchuca HARP
The team currently works with between 35-40 clients per month
Though the majority of clients are within the older age range we are receiving more referrals for younger clients
What we have achievedWhat we have achieved
Over the past 3 years we have
achieved the following:Client BrochureIncreased referral rateHave referrals from a diversity of
sources
What we have achievedWhat we have achieved
Developed a relationship with the Emergency Department and increased our referral rate from this department
Have begun to develop a relationship with Aboriginal services via the Aboriginal Chronic Illness Co-ordinator
What we have achievedWhat we have achieved Have referrals triaged via the Referral Centre Improved paperwork and processes IE.– Admission and Discharge Checklist
– Assessment form and checklists for Cardiac, Diabetes
– Spreadsheet to track unplanned admissions
What we have achieved:What we have achieved:
Worked with clients in more structured time frames
Professional development in:
-Motivational Interviewing
- Chronic Illness Online Course
- Flinders Model etcPreparatory work for Activity Based
Funding
The FutureThe Future
Consolidation of the work that has been done
Continuous improvement in terms of skills working more effectively with clients, paperwork and processes
The FutureThe Future
Utilisation of disciplines with the team
Work to improve relationship with GP’s
Work with other Health Independence Programs to improve service to clients
Aim to meet the new national standards
