Echuca Regional Health Hospital Admissions Risk Program – HARP Martin Pugh April 2013

1. Echuca Regional HealthHospital Admissions Risk Program – HARPMartin PughApril 2013

2. 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.

3. Why • 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

4. Key Objectives of HARP • Improve client outcomes • Provide 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

5. Eligibility Criteria • HARP 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

6. How 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

7. How 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

8. The Client Journey • Like clients from other Health Independence Programs HARP clients go down the following journey

9. The Client Journey • Access • Initial Needs Identification • Assessment • Client Consent • Care Planning and Implementation • Monitoring and review • Transition and exit

10. Echuca 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

11. 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

12. Echuca 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

13. What we have achieved Over the past 3 years we have achieved the following: • Client Brochure • Increased referral rate • Have referrals from a diversity of sources

14. What 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

15. What 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

16. What we have achieved: • Worked with clients in more structured time frames • Professional development in: -Motivational Interviewing - Chronic Illness Online Course - Flinders Model etc • Preparatory work for Activity Based Funding

17. The Future • Consolidation of the work that has been done • Continuous improvement in terms of skills working more effectively with clients, paperwork and processes

18. The 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

19. Martin Pugh • Phone: • Email: mpugh@erh.org.au