Department of Human Services

The Practice Standards for the The Practice Standards for the Implementation of Care Planning in VictoriaImplementation of Care Planning in Victoria..

Presented by: Kate Boucher, Integrated Chronic Disease Management Team & Shelly Lavery, Partnerships Team.

Primary Health Branch

Care Planning in VictoriaCare Planning in Victoria

• What is Service Coordination?• Where does care planning fit into

service coordination?• What is a care plan?• What is the role of the Key Worker?• Practical activity• Care Planning Project 2007 - 2009

Service CoordinationService Coordination

Better Access to Services Better Access to Services BATS BATS (2001)(2001)frameworkframework

• Service coordination is underpinned by consumer focus, social model of health, partnership & collaboration, competent staff

• Significant change required to embed all elements of service coordination

–Systems & processes, cultural-organizational & individual

What does Service Coordination What does Service Coordination mean to our consumers?mean to our consumers?

• Easy, visible ‘entry’ into the system

• Their full range of needs are identified as early as possible

• They are treated as a whole person

• Information about all services are up to date and readily available

• They don’t have to retell their story every-time they see a new service

• They control who and what information is shared

Elements of Service CoordinationElements of Service Coordination

Service Coordination ProgressService Coordination Progress

87%

6%

Not applicable

No response

Less than 10%

Between 10-50%

Between 50-90%

More than 90%

Acknowledgement of urgent referrals within 2 working days

Initial Needs Identification is conducted within 7 working days of initial contact

71%

18%

Not applicable

No response

Less than 10%

Between 10-50%

Between 50-90%

More than 90%

Service Coordination Survey 2008

Care Planning ResultsCare Planning Results

15%

13%

21%

9%

38%

Not applicable

No response

Less than 10%

Between 10-50%

Between 50-90%

More than 90%

Service Coordination Survey 2008

Service Coordination Plans have been documented for consumers with complex or multiple needs who are receiving services from more than one agency.

36%

22%

10%

27%

4%

Not applicable

No response

Less than 10%

Betw een 10-50%

Betw een 50-90%

More than 90%

When there is a Service Coordination Plan, the consumer's GP has a copy of the agreed Service Coordination Plan (if appropriate).

Service Coordination Service Coordination ProgressProgress

• Care planning is an integral element of service coordination

• BUT …..still a complex area which generates many questions……

What is Care Planning? What is Care Planning? • Care planning required whenever assessment

occurs• Dynamic process that incorporates care

coordination, case management, referral, feedback, review, re-assessment, monitoring and exiting

• Care planning involves discussion, negotiation and decision making between service provider and consumer to define goals and strategies, then identify actions and service to meet those goals.

• Can be at a number of levels- single service, or a number of services both within (intra-agency) & across agencies (inter-agency)

Where does Care Planning fit?Where does Care Planning fit?

•Service specific

•Intra-agency care plan

•Inter-agency care plan

What are the Benefits of Care What are the Benefits of Care Planning?Planning?

• Assists consumers in achieving goals• Encourages active participation• Manages long term care/continuity• Provides documentation• Encourages a team approach• Proactive rather than reactive• Increases consumer awareness of services • Effective monitoring

Key Features of Care Planning in Vic.Key Features of Care Planning in Vic.

• Nominate single key worker who has a specific role and responsibilities

• Incorporation of care planning activities• Provision of effective monitoring• Coordination of referrals & feedback• Maximise collaboration with GP• Use of SCTT Templates

Care Planning in Context of Care Planning in Context of Chronic Disease Chronic Disease ManagementManagement

• Particularly important in facilitating appropriate care for consumers with chronic and complex needs who require multiple services.

• Consumers with chronic conditions may require care planning at all levels – single service plan, intra-agency and inter-agency

• Must have a coordinated response across services and communication between service providers

Person Centred PracticePerson Centred Practice

• Partnership approach to care• Holistic approach to practice• Value of the role of family/carers• Support consumer to identify own

needs/goals• Encourage consumer decision making• Support autonomy and choice

What is in a Care Plan?What is in a Care Plan?

• Date care plan developed• Participants• Consumer stated agreed issues/problems• Consumer stated agreed goals• Agreed actions/responsibilities/timeframes• Planned review date• Consumer acknowledgement of care plan• Actual review date

Key Worker RoleKey Worker Role is likely to is likely to involve:involve:

• Engaging and empowering the consumer and acting as an advocate as required

• Consolidating assessment or care plans• Good knowledge of existing services• Developing/documenting agreed

goals/actions in collaboration (SMART)• Facilitate the creation, documentation and

communication of initial care plan• Monitoring and review

Key Worker contin…………Key Worker contin…………

• Liaising and communicating with participants• Organising & facilitating the case conference• Working in virtual/multi/inter discipline team• Discussing exit options and procedures• Feedback to referrers, GP & support workers• Ensuring documentation meets requirements

of privacy legislation

MonitoringMonitoring

Care Planning includes monitoring to ensure service is delivered as intended and is fulfilling the agreed goals. The role of the key worker and monitoring processes will be developed in the future.

GP Involvement in Care GP Involvement in Care PlanningPlanning

• Involvement by GPs is the care planning for people with chronic/complex needs is essential

• Communicate with GP’s to determine if there is an existing care plan

• A copy of any developed care plan should be provided to the GP

• CDM items available to General Practice- Team Care Arrangement

How Can Agencies Support How Can Agencies Support the Process of Care Planning?the Process of Care Planning?

• Documented protocols • Documented care pathways• Up-to-date resources for staff• Relevant staff training • Defined practices/processes/protocols/system• Agreements between services (+GP’s)• Defined processes for monitoring, review,

recall

Good Practice IndicatorsGood Practice Indicators

• VHA Indicators

• Service Coordination Manual

• Consumer Outcomes

Care Plan ElementsCare Plan Elements

1. Date care plan developed2. Client stated/agreed issues/problems3. Client stated/agreed objectives/goals,

4. Client stated/agreed strategies/action

5. Timeframe for attainment of objectives/goals

6. Responsibilities for implementing strategies/action

7. Participants in development of care plan

8. Consumer Acknowledgement (signed or verbal acknowledgement recorded)

9. Review date of care plan (planned and actual)

10.Goal attainment

ActivityActivity

The answers you seek……

……are in this room

Steps to Develop A Care Plan Steps to Develop A Care Plan ActivityActivity

1. Does this person need a Care Plan?2. What other care plans could this person already have? 3. How would you explain to this person what a care plan is and why you think

they will benefit?4. How do you obtain consumer consent to the care planning process?5. Who are the people that need to be involved?6. How would you obtain and record consent to share information?7. How would you organise a case conference and who would be involved?8. How would you agree on who the key worker would be?9. Record all participants in care, their role and contact details.10. Identify key issues, agreed goals (SMART), actions, responsibilities/target

dates for each goal.11. How do you decide on the review date?12. How would you be confident that the consumer understands and agrees on

the plan?

Care Planning Project 2007-2009Care Planning Project 2007-2009

• Initially developed to progress inter-agency care planning through PCPs

• Care planning seen as a complex area requiring experienced practitioners able to coordinate care using a comprehensive person centred approach

• Basic elements & principles of person- centred coordinated care planning not well known

Care Planning Project found:Care Planning Project found:

• Care planning practice inconsistent at inter-agency and intra-agency level• Care planning seen as a complex area

requiring experienced practitioners able to coordinate care using a comprehensive person centred approach

• Basic elements & principles of person- centred coordinated care planning not well known

Why has it been difficult?Why has it been difficult?

• Increasing complexity & diversity within the service system itself

• Diverse range of workers with different skills, qualifications and value bases.

• Varied & inconsistent practice & approaches resulting in different outcomes for consumers

Key Issues Identified Through Key Issues Identified Through Care Planning ProjectCare Planning Project

• CP project identified skills & knowledge gaps, need for change management, definitions, guidelines, tools

• Gaps in knowledge and skills in care planning • Definitions, guidelines not consistent • Lack of a consistent approach at DHS

program level- policy & operational guidelines

Need for DHS Response to Need for DHS Response to the Sectorthe Sector

• To improve care planning practice at all levels

• Provide resources to support systems development

• Opportunity to start process of integration of consistent principles and guidelines across programs where possible

Tools and ResourcesTools and Resources

• Service provider or program Care Planning Guidelines and tools • Service Coordination Tool Templates (SCTT) Care Coordination

Plan• SCTT 2009 User Guide www.health.vic.gov.au/pcps/coordination/sctt2009.htm

• Service Provider policies: Eligibility, criteria, priority, access• The human Services Directory www.humanservicesdirectory.vic.gov.au

• MBS care planning items www.health.vic.gov.au/communityhealth/gps/mbs/care_planning.htm

• Integrated Health Promotion Tool Kit www.health.vic.gov.au/healthpromotion/downloads/integrated_health_promo.pdf

• Training resources www.health.vic.gov.au/pcps/coordination/index_workforce.htm