ACI Building Partnerships: A Framework for Integrating Care for Older People with Complex Health Needs
Project activity so far:
Previous work: Assessing risks associated with waiting for older people with complex health needs attending TTH ED. Data revealed the majority (86%) of these patients live in the community and not RACF, as perceived by TTH ED staff. 70% RACF residents leave TTH ED within 1 hour of treatment cessation. Nil significant adverse incidents have been reported when patients wait for transport. This predominantly reflects an effective partnership between ED staff and PTV / Ambulance. Discharge summaries from ED were very timely, but not from wards. This issue has been elevated & now addressed. TTH reinstated Yellow Envelope to improve communication between TTH and RACF.
Current project. A community based approach to improving care for the older person with complex health needs experiencing early cognitive decline. A delay in receiving best practice care has been identified for people living in the Tweed region who experience cognitive impairment. The delay is understood to be 2 fold: from when a person first acknowledges cognitive impairment to when they seek medical attention; A further delay is documented after first seeing a medical practitioner to diagnosis. Additionally, Health & Service provider organisations have limited processes to share cognitive information about a consumer. This can have a negative impact upon the consumer’s health care.
- Community consultation- NCPHN 2016 Needs Assessment
- Partnership consultation – Focus groups 8th and 15th March 2016
- Data collection- ED admission data, Health Record audits
- Consumer / Carer stories, Process mapping
- Literature search to best practice / 2016 Clinical Guidelines
Solution design workshop 14th June 2016 and Solution Report drafted. Next step: conduct smaller working groups to draft Implementation Plan.
- Improve health literacy – Education message to community and stakeholder forums on benefits of early identification.
- Cognitive screening training including a range of screening tools to community providers e.g. EPIC, HCP; and NNSW Health – Aboriginal Health, ASET, CDMP
- Engage with GPs: GP forum, promote Health Pathway, benefits of progressive screening results for high risk group, navigating aged care.
- Populate progressive scores in GP Summary and cognitive scores in discharge summaries; community Yellow Envelope to service providers.
Implementation and Evaluation Plan
Implementation planning to commence August 2016
Sustainability of Framework process and project
- Identifying on going roles
- Stakeholder consultation and linking of Stakeholder forums
- GP forum November 2016
- Health literacy printing
- IT support, space to populate progressive cognitive scores in GP summary and in discharge summaries and letters from Acute to Primary health care.