“Through the Eyes of the Client”€¦ · Warren Haynes Brotherhood of St Laurence Judy Allen...

FMPPCP – ‘Through the Eyes of the Client’ - Client Journey Experiential Study 2010 | 1

““TThhrroouugghh tthhee EEyyeess ooff

tthhee CClliieenntt””

((CClliieenntt JJoouurrnneeyy EExxppeerriieennttiiaall SSttuuddyy))

Frankston/Mornington Peninsula Primary Care Partnership

December 2010

A Healthy & Connected Community

From the clients’ perspective

From the service providers’ perspective


FRANKSTON/MORNINGTON PENINSULA

PRIMARY CARE PARTNERSHIP

“THROUGH THE EYES OF THE CLIENT”

(CLIENT JOURNEY EXPERIENTIAL STUDY)

Authors

Lyn McKay, SSR Coordinator, Frankston/Mornington Peninsula Primary Care Partnership

Julie White, ICDM Support Officer, Frankston/Mornington Peninsula Primary Care Partnership

Consultants

John Hoogeveen, Principle, Revive Consulting Pty. Ltd.

Susanne White, Consultant, The Resolutions Group

©Frankston/Mornington Peninsula Primary Care Partnership, December 2010

This publication is copyright. No part may be reproduced by any process except in

accordance with the provisions of the Copyright Act 1968.

Sponsored by the FMPPCP Service System Redevelopment Committee with PCP

funding from the Department of Health.

Correspondence to: FMPPCP, Service System Redevelopment Coordinator

P O Box 192, Mt Eliza, VIC 3930


LETTER FROM FMPPCP CHAIR

December 2010

Dear Colleagues and Friends,

It is with great pleasure that, on behalf of the Frankston/Mornington Peninsula Primary Care Partnership

(FMPPCP), I recommend the “Through the Client’s Eyes – Client Journey Experiential Study” Report to

you.

This report is the culmination of dedicated work carried out by FMPPCP service providers over the last 12

months and clients who have likewise participated enthusiastically in the study. It documents the actual

experiences of clients using the service system in the Frankston/Mornington Peninsula area and provides

important information and data from service providers.

It is hoped that, as a result of the study findings, all clients using the health care system will ultimately

benefit from enhancements in service coordination and chronic disease management due to the increased

ability of PCP organisations to focus on targeted areas for improvement identified through the study.

In real terms the Client Journey Experiential Study will be used by service providers to make sure clients

and their carers are able to receive care that optimises their health and quality of life. It also provides

information that will inform the things we need to do to provide better access to services for clients when

and where it is needed.

We recognise the importance of the continual need for systemic reforms to improve health care. The

ongoing work of our PCP, as a result of the report findings, will enable the system improvements

necessary to make sure clients will have timely access to the most appropriate services and access to a

system which is able to proactively identify, respond to and support client and carer needs. It ensures

improvements that will enhance coordinated delivery of services and enable the type of care and support

that is appropriate to clients’ cultural backgrounds, circumstances, needs and preferences.

Congratulations to all participants and those who have worked tirelessly on this project providing a rich

wealth of information to guide our efforts into the future for better health service delivery for all clients in

the Frankston/Mornington Peninsula area.

Yours sincerely,

Dr. Gillian Kay

Chair

Frankston Mornington Peninsula Primary Care Partnership


CONTENTS

ACKNOWLEDGEMENTS .............................................................................................................. 5 EXECUTIVE SUMMARY .............................................................................................................. 6

INTRODUCTION & BACKGROUND............................................................................................ 10

INTRODUCTION.................................................................................................................... 11 BACKGROUND ..................................................................................................................... 13 KEY OBJECTIVES OF THE STUDY................................................................................................. 13 SCOPE OF STUDY ................................................................................................................. 13 CLIENT INCLUSION CRITERIA ................................................................................................... 14 FMPPCP CATCHMENT DEMOGRAPHICS ........................................................................................ 14 CONTEXT ........................................................................................................................... 16

METHODOLOGY .................................................................................................................. 19

METHODOLOGY.................................................................................................................... 20 CONDUCT OF A CLIENT SURVEY................................................................................................. 20 CONDUCT OF A SERVICE PROVIDER SURVEY .................................................................................. 20 GOVERNANCE STRUCTURE ....................................................................................................... 21 PARTICIPANTS ..................................................................................................................... 21

LIMITATIONS OF THE STUDY....................................................................................................221

CONSULTATION FINDINGS.................................................................................................... 23

KEY FINDINGS..................................................................................................................... 24

THEMES FROM CLIENT GROUPS ................................................................................................. 27

SURVEY RESULTS - CLIENTS ................................................................................................. 32

CLIENTS ............................................................................................................................ 33

SURVEY RESULTS – SERVICE PROVIDERS ................................................................................. 65

SERVICE PROVIDERS ............................................................................................................ 66

TABLES OF FIGURES ......................................................................................................... 111

BIBLIOGRAPHY ................................................................................................................ 113

TERMINOLOGY ................................................................................................................. 114

APPENDICES ................................................................................................................... 118


ACKNOWLEDGEMENTS

The contribution of the following individuals in the conduct of the Client Journey Experiential

Study is gratefully acknowledged:

Client Journey Working Group Members

Warren Haynes Brotherhood of St Laurence

Judy Allen Commonwealth Carer Respite Carelink

Julie Rooney Frankston City Council

Lyn McKay FMPPCP

Leisl Jackson Peninsula GP Network (PGPN)

Jesinta Klufer MEACAS

Dee Petch Mind Australia

Julie Cahill Mornington Peninsula Shire

Julie White Peninsula Health Community Health/FMPPCP

Jean Phillips Peninsula Health Community Health

Carolyn Marshall Peninsula Health Community Health

Susan Dal Lago Peninsula Health Community Health

Nikki Hale Care in Your Community, Peninsula Health

Alan Carlow Peninsula Health Mental Health Services

Claire Harris RDNS

Sarah de Lange RDNS

Jenny Gillespie Villa Maria, Southern Community Services

Questionnaire Development Task Team

Warren Haynes Brotherhood of St Laurence

Julie Cahill Mornington Peninsula Shire

Alan Carlow Peninsula Health Mental Health Services

Julie White Peninsula Health Community Health/FMPPCP

Lyn McKay FMPPCP

Consultants

John Hoogeveen, Principal, Revive Consulting Pty. Ltd.

Susanne White, Consultant, The Resolutions Group Pty. Ltd.

Acknowledgement and thanks to those clients who have willingly and enthusiastically

participated in the consultations and provided rich feedback to inform the development of the

regional priorities.

Also acknowledgement and thanks to all the service providers - practitioners, clinicians and

service managers – who made time in their busy schedules and were very candid in their

responses to provide the rich data and service review activities for the client journey

experiential study. A special thanks to those who organised the focus groups and provided

venues.

Thanks to Mornington Peninsula Shire and Peninsula Health for providing meeting rooms for

the project Working Group and Task Team.


EXECUTIVE SUMMARY Sitting within the context of the extensive strategic and operational planning work undertaken

by the Frankston and Mornington Peninsula Primary Care Partnership (FMPPCP) the Client

Journey Survey was considered to be an important ‘next step’. Identified as a key strategic

priority designed to support further service system redevelopment work under the auspices of

the Service System Redevelopment (SSR) Committee, the Client Journey Experiential Study

was conducted as a primary quality improvement process to enable PCP service providers to

obtain a better understanding of what is working for clients and what is not.

Conducted across a range of FMPPCP Clients and Service Providers the study seeks to provide

the incentive and opportunity to rethink and increase capacity to make the necessary

adjustments across the full service coordination spectrum to improve the care coordination of

clients.

“Through the Eyes of the Client” Client Journey Experiential Study documents and analyses the

experiences of the service system by clients with chronic and complex conditions who were

multiple service users through the service system over a specific period. It also documents

and analyses the system from a service provider perspective.

The key objectives of the study are to:

• empower clients to navigate the service system and manage their needs across the

continuum of care.

• use a service system redevelopment approach to identify gaps and areas for

improvement, and to recommend changes that will improve the client journey and

outcomes.

• enable the development and trial a service system redevelopment (SSR) approach which

could be used by the Primary Care Partnership to make improvements across the

catchment.

The study supports FMPPCP’s ability to:

• Document and gain an understanding of the experiences, health and wellbeing outcomes

for clients accessing and using the health care system.

• Identify the experience of clients with chronic and complex conditions of the health

service system.

• Identify barriers and concerns that exist for clients.

• Identify systems that promote information sharing and care coordination as identified by

clients.

• Identify future work to target specifically identified areas where gaps in service access

and good care coordination practice exist.

• Obtain robust data from service providers of current service coordination practice and the

client journey from their perspective.

In the conduct of the study a quantitative and qualitative approach with thematic and data

analysis was undertaken. The resultant findings and report makes available in depth

information, both quantitative and qualitative, about clients’ experiences of the health system

in the catchment and robust data from service providers.

The study was conducted via of a series of focus groups engaging consumers and individual

consumer interviews using a questionnaire developed by the PCP SSR Client Journey Working

Group. Also an extensive Service Provider Survey, using Survey Monkey, completed by PCP

member agencies was conducted.


The conduct of the Client Journey Study has been instrumental in achieving extensive

partnership engagement resulting in the strengthening of partnerships and client engagement

across a wide range of sectors and target populations.

PARTICIPANTS – AT A GLANCE A total of 147 clients (clients, carers, family) from a variety of agencies and groups

participated in the study. This exceeded the project parameter of engaging between 80-120

client participants.

A total of 87 service providers participated in the Service Provider survey process representing

a broad cross section of the 35 PCP member agencies. The resultant participation numbers are

considered to have strengthened the robustness of the study result and be representational of

broad client and service provider opinion.

Clients from various agencies and community groups and fitting within the project profile,

participated in a series of focus groups. They were invited to complete a questionnaire

developed specifically for the survey. There was also opportunity for general discussion,

particularly centred on the open ended questions contained within the questionnaires. Of 147

clients 79 completed questionnaires while the remainder participated in the general discussion

and also in a series of individual client interviews – some face to face and some over the

telephone.

A service provider survey was conducted on Survey Monkey using a questionnaire based on

the service coordination framework1 and chronic disease management guidelines2. It was

completed by services/programs within the target sectors from a broad cross-section of

FMPPCP members.

SUMMARY OF KEY FINDINGS The study identified many things that are being done well by service providers from their

perspective and also from the clients’ perspective. The vast majority of those who participated

in the study believe they are most fortunate with the current service system. Overall there

were many positive comments such as “………. I do think the public system is very good”,

reflecting clients’ satisfaction with the system and with the services they receive from service

providers.

However, the study identifies a number of gaps in the system and challenges to be met by

service providers, organisations and the catchment as a whole. Of interest is the apparent

‘contradictory’ nature of some comments and responses to the survey questions by both

clients and service providers alike illustrating the diversity and often conflicting nature of

perceptions of the health care system. The key findings are as follows:

� Key client expectations identified were to:

� be able to access the services they require in a reasonable period of time

� receive help and be looked after and be given information appropriate to

their situation

� Key client best experiences of the system were those that:

1 Primary Care Partnerships, Victoria, Victorian Service Coordination Practice Manual 2009 2 State of Victoria, Primary and Community Health Branch, Victorian Government Department of Human Services, Melbourne,

Victoria, Revised Chronic Disease Management Program Guidelines for Primary Care Partnerships and Primary Health Care Services, October 2008


� involved successful and timely responses to clients’ concerns

� related to particular programs where the leader provided friendly and

appropriate service, tailored for the individual client’s needs.

� Key client worst experiences of the system were those that included:

� slow responses or lack of timeliness in a range of situations

� apparent lack of concern or interest in the individual client

� service providers not taking the time to listen or pay proper concern to the

client needs and issues

� Clients identified being listened to and ‘really heard’, treated with decency, courtesy,

respect and have timely follow through as most important to them. The importance of

effective communication between services and their clients was a major theme throughout

the study.

� The influence of social and environmental determinants of health and wellbeing and how

they contribute to the maintenance of health and wellbeing has been identified as an

important factor to clients feeling supported to adopt and maintain a health lifestyle.

� The wide variety of structures from centralised access systems to multiple entry systems is

confusing for clients to navigate although most clients indicated they found it reasonably

easy to get into services when they had needed one in the past twelve months. However,

the length of time to access any service was still of concern to many others.

� Generally clients indicated that they may receive adequate information about services and

health related issues but there was some degree of difficulty in applying this on a day to

day basis.

� In the health system the GP is seen by clients to be the primary service provider and

indicated as the first point of contact priority. The hospital was indicated as clients’

second point of contact which has major implications for emergency presentations.

� Many clients did not see that they actually had a ‘condition’. This raises interesting and

challenging issues about the terms used in consultation with clients.

� Despite the majority of service providers indicating consistent care planning practice there

is still demonstrated variable practice among service providers. There appears to be

inconsistency between what service providers report in relationship to care planning and

the perception of clients. For instance, from many clients’ perspectives written care plans

are not always provided to clients.

� Consent to share personal details and information remains a contentious issue with most

service providers indicating they ask for clients consent to share. This is at odds with the

perception of clients who stated (52%) that they had not been asked to give consent prior

to sharing their information to other services.

� Diverse communication practice exists between service providers and GPs. There appears

to be a lack of consistency in feedback and involvement with G.P.’s in the care planning

process. Given that clients see the GP as central to their first point of call and often as

their ‘care coordinator’ this has major implications for appropriate care coordination and

streamlined care between services. This is of particular concern for the management of

clients with complex care needs.


� Some clients noted that services did not involve carers enough, even though carers took

full time responsibility for meeting the needs of the client outside the service.

� Based upon the study findings review of current practices and adoption of appropriate

systems for followup/recall/review for clients is an area that requires additional attention at

an organisational and practice level.

� Clients value service providers being able to link them into appropriate services as part of

the follow through role.

� Clients needs beyond the presenting issue do not appear to be systematically or

consistently flagged for their broader needs as evidenced in relation to clients with

dementia, depression or anxiety.

� There is evidence of a lack of clarity by service providers around what is Client Focused

Care despite the majority of service providers indicating that this is a high practice priority.

� There are extensive service provider practice variations between referral timeframes

and transmission of referral acknowledgements. This reinforces the need for the

development of local agreements for referral and for clear feedback mechanisms

agreed upon by services to embed formalised communication processes for service

provider/GP communication.

Full details of the study findings in this summary are provided in the remainder of this report.

The study is a beginning not an end in and of itself therefore does not by itself equate to

service system improvements. These can only occur as service providers are willing to

embrace the challenges of change and engage in true system reform and improvements in

practices and processes. The challenge for the future will be to adequately respond to clients

and to continue to establish systems, practices and processes that enable service system

issues to be further addressed.


CLIENT EXPERIENTIAL STUDY

INTRODUCTION & BACKGROUND


INTRODUCTION

Making Clients Experiences Count!

The primary aim of the Department of Health’s Better Access to Services (BATS) strategy

focuses on the client as the central focal point of service coordination3. It aims to improve

client experience of the primary health service system and as much as possible “prevent the

person from having to tell their story over and over again” when they access the health

system. The BATS strategy clearly outlines the principles for client responsiveness4 which

includes:

• Sensitivity to the issues of age, religion, gender and language.

• Clients’ expectations are taken into account, their personal capacity to make informed

choices about their health and well-being is paramount and self management is

encouraged5.

In the Service System Redevelopment Strategic Plan 2009-2012, the FMPPCP committed to

conducting an assessment of client experience of the current service system. This study was to

be an experiential study involving participation by informed clients and service providers.

Making the System Count!

The Clients

Through the conduct of the study the FMPPCP tested the system – how it works from a client

perspective and responds to their needs and expectations. The intention of the client journey

experiential study is to provide the evidence base necessary to undertake targeted

improvements across the system and within PCP member agencies.

The Service Providers

Also through the conduct of the study the FMPPCP tested the system and how it works from a

service provider perspective. This provides an excellent comparative from two very different

perspectives and perceptions of how things work.

Making the study count! This study is designed to support PCP member agencies quality improvement processes. It is a

major step in promoting an informed and clearly targeted long term strategic approach to

planning and activity in the FMPPCP to improve health outcomes, self management capacity,

health service orientation, and clinical practice change.

The findings in this study will enable PCP service providers to obtain a better understanding of

what is working for clients and what is not. It provides incentive and opportunity to rethink and

3 State of Victoria, Better Access to Services – A Policy and Operational Framework, June 2001, Victorian Department of

Human Services 4 Responsiveness refers to a number of elements of the ways health systems interact with people. These include: being

treated with dignity, being attended to promptly, having autonomy, having personal information kept confidential, having a choice of health care provider, having the health care provider communicate with you in a way you understand, having access to social support during care, and having amenities in the health care environment that are of an acceptable standard (WHO, Description of the Key Informant Survey, WHO International). 5 State of Victoria, Better Access to Services – A Policy and Operational Framework, June 2001, Victorian Department of

Human Services


make the necessary adjustments across the full service coordination spectrum to improve the

care coordination of clients.

The study has given us hard data. It is a valuable tool for planning and decision making and

will be utilised extensively by PCP service providers to inform these processes. It will increase

the capacity of FMPPCP service providers to make service improvements and innovations to

benefit clients and service providers alike.

The conduct of the Client Journey Study has been an instrument for extensive partnership

engagement resulting in the strengthening of partnerships and client engagement across a

wide range of sectors and target populations including:

• Mental Health

• Aged

• Local Government

• GPs

• Drug and Alcohol

• Acute

• Sub Acute

• Community

• Disability

• Neighbourhood/Community Renewal

• Indigenous

• Culturally And Linguistically Diverse (CALD)


BACKGROUND Subsequent to a rigorous consultative planning process among Frankston Mornington Peninsula

Primary Care Partnership (FMPPCP) members at the commencement of 2009, the Client

Journey was identified as a strategic priority for the Service System Redevelopment (SSR)

work to be undertaken over three years. This was reflected in the FMPPCP Strategic Plan SSR

Plan 2009-2012. All the work undertaken in this project mirrored the objectives, strategies,

outcomes, and impacts detailed in the FMPPCP Strategic SSR Plan.

The overarching strategic objectives identified by FMPPCP members through the plan were to:

1. Build a common understanding of the service system within and across all agencies.

2. Strengthen the catchment’s continuum of care from prevention, early identification, to

Integrated Chronic Disease Management (ICDM) to maximise the health, well being and

connectedness of individuals, families and communities.

3. Enhance the capacity of individual agencies (intra agency) and agencies in partnership (inter agency) to meet the requirements of the Victorian Service Coordination practice

standards and Chronic Disease Guidelines and to provide best practice care in keeping

with other recognised quality standards and evidence based standards.

Through the planning processes, FMPPCP member agreed that the service system

redevelopment work would have a central focus on the following cohort and disease lens to

provide a focal point for the work to be undertaken:

• Ageing

• Anxiety and Depression

• Dementia

During the latter part of 2009 work commenced on undertaking the Client Journey Experiential

Study using a solid project management approach as the foundation to undertake the process.

KEY OBJECTIVES OF THE STUDY • To empower clients to navigate the service system and manage their needs across the

continuum of care.

• To use a service system redevelopment approach to identify gaps and areas for

improvement, and to recommend changes that will improve the client journey and

outcomes.

• To enable the development and trial a service system redevelopment (SSR) approach

which could be used by the Primary Care Partnership to make improvements across the

catchment.

SCOPE OF STUDY “Through the Eyes of the Client” followed and documented the journey of a sample group of

clients who are multiple users of the service system over a specific period. In accordance with

the Service System Redevelopment Strategic Plan 09-12, the population cohort and disease

lens for the project was in keeping with the identified focuses of Aging, Anxiety and Depression

and Dementia. It also collected baseline data from service providers and documented their

current service coordination and chronic disease management practices.

The study included assessment of:

• Access/intake


• Exit/discharge

• Assessment and care planning

• Referral

• Care coordination

• Self management

• Early intervention in chronic disease

• Capacity of organisations – limitations to go beyond presenting issue or service programs

• Communication between providers

• Strengths and weaknesses of client journey processes for client feedback and quality

improvement

CLIENT INCLUSION CRITERIA The Clients who participated in the study generally fell within one or several of the following

inclusion criteria:

• primarily between the ages of 50-80

• had multiple agency involvement

• had multiple co-morbidities

• met the profile for the anxiety and depression/dementia focus of the study

• may be a member of a CALD group

• may be an Indigenous person

• may be a family carer or have a personal / family carer

• had relevant and current experience of the health system, and

• had the ability or assisted capacity to explain weaknesses/difficulties and express how

they think the system could improve

Participating clients also had a:

• mix of various types of living arrangements

• mix of differing socio economic backgrounds

FMPPCP CATCHMENT DEMOGRAPHICS6

The Frankston Mornington Peninsula Primary Care Partnership (FMP PCP) is based in two local

government municipalities, Frankston City and Mornington Peninsula Shire - referred to as the

‘sub-region’.

The sub-region comprises the City of Frankston, and is broadly characterised by a younger

population in Frankston City and an older population in the Mornington Peninsula Shire, with a

number of socio-economic issues impacting on the health and well-being of residents,

including, early school leavers, low incomes, and smaller numbers of people with formal

qualifications.

Topography of the Mornington Peninsula is such that some communities are relatively isolated

and there are significantly lower proportions of its population who do not speak English well or

not at all compared with Melbourne. An indigenous community is also present.

6 Sourced from: FMPPCP Strategic Plan: Evidence Base for 2009-2012 Priorities – Community Profile - includes data from the

Community Health Planning Data Sets 2008 – Social Demographic Data 2007., DHS


POPULATION FRANKSTON

2007 population by age and sex

Age Females Males Total

% total

Frankston

population

% total

Victorian

population

0 - 14 12,108 12,436 24,544 19.9% 18.9%

15 - 24 8,488 8,638 17,126 13.9% 14.0%

25 - 44 17,691 17,554 35,245 28.6% 29.1%

45 - 64 15,487 14,858 30,345 24.6% 24.6%

65 – 84 7,562 6,239 13,801 11.2% 11.8%

85+ 1,377 689 2,066 1.7% 1.7%

Total 62,713 60,414 123,127 100.0% 100.0%

FRANKSTON’S CALD POPULATION Frankston City has a lower percentage of people from Culturally and Linguistically Diverse

backgrounds than the Melbourne Statistical Division, however this is changing with Frankston

City becoming more culturally diverse than in previous years.

Frankston City has a relatively young population with over 26 per cent of residents

aged under 17, and 72 per cent aged under 49 years. Residents were mostly born in Australia

(73 per cent), the United Kingdom (9.9 per cent), and New Zealand (1.9 per cent. There is a

population of 9280 from culturally and linguistically diverse (CALD) backgrounds or 8.5 per

cent of the total population. Between 1991 and 2001 the population of CALD people in

Frankston City had increased by 15 per cent. In particular, there has been an increase in the

number of those born in Croatia, Bosnia and Herzegovina, China and Fiji7.

POPULATION MORNINGTON PENINSULA

2007 population by age and sex

Age Females Males Total % total Morn.

Pen. population

% total Victorian population

0 - 14 12,677 13,676 26,353 18.5% 18.9%

15 - 24 7,951 9,140 17,091 12.0% 14.0%

25 - 44 16,918 15,871 32,789 23.0% 29.1%

45 - 64 19,840 18,365 38,205 26.8% 24.6%

65 – 84 13,016 11,676 24,692 17.3% 11.8%

85+ 2,229 1,220 3,449 2.4% 1.7%

Total 72,631 69,948 142,579 100.0% 100.0%

MORNINGTON PENINSULA’S CALD POPULATION As at June 2004, the Mornington Peninsula population was comprised of 6.4% of people born

in predominantly non-English speaking countries and resident in Australia for five years or

more considerably lower than the proportion in Melbourne (17.5%).

7 http://www.frankston.vic.gov.au/About_Frankston_City/Demographics/index.aspx


Recent arrivals (those resident in Australia for less than five years) from non-English speaking

countries comprised just 0.7% of the Mornington Peninsula population (compared to 3.1% in

Melbourne). Of these residents, 0.6% had poor proficiency in English (determined when

people aged five years and over born overseas in predominantly non-English speaking

countries reported in the Census speaking another language and speaking English ‘not well’ or

‘not at all’), lower than the proportions in Melbourne (4.4%) and Victoria (3.4%) and Australia

(2.4%)8

CONTEXT The clients’ experience of health care occurs in the context of the health system as a whole in

relationship with key government policies and initiatives such as Active Service Model (HACC),

Health Independence Program (HIP), Early Intervention in Chronic Disease (EIiCD), Care in

Your Community along with the Victorian Service Coordination Practice Manual (VSCPM) and

the Department of Health’s Chronic Disease Management Guidelines.

POLICY CONTEXT The Service System Redevelopment Client Journey Experiential Study was undertaken in the

context of directions set by Federal and State government policies and guidelines including:

• “Better Access to Services”9

• “Revised Chronic Disease Management Guidelines 2008” 10

• “Growing Victoria Together”11

• “Care in Your Community”12

• National HACC Program Guidelines 200713

• Victorian HACC Active Service Model Implementation (ASM) Plan 2009-201114

• Victorian Service Coordination Practice Manual15

• Good Practice Guide (For Practitioners)16

• Service Coordination Continuous Improvement Framework17

8 http://www.pgpn.org.au/download/pdf/Strategic%20Plan_PGPNDemographics.pdf

9 State of Victoria, Aged, Community and Mental Health Division, Victorian Government Department of Human Services,

Melbourne, Victoria, Better Access to Services – A Policy and Operational Framework- Primary Care Partnerships, June 2001

10 State of Victoria, Primary and Community Health Branch, Victorian Government Department of Human Services,

Melbourne, Victoria, Revised Chronic Disease Management Program Guidelines for Primary Care Partnerships and Primary Health Care Services, October 2008

11 State of Victoria, Victorian Department of Premier and Cabinet, Victorian Government, Melbourne, Victoria, Growing

Victoria Together: A Vision for Victoria to 2010 and Beyond, 2001

12 State of Victoria, Victorian Government Department of Human Services, Melbourne, Victoria, Care in Your Community – A

Planning Framework for Integrated Ambulatory Health Care, 2006 13 Commonwealth of Australia 2007, Australian Government Department of Health and Aging, National HACC Program

Guidelines for the Home and Community Care Program, 2007

14 State of Victoria, Victorian Department of Health, Victorian HACC Active Service Model Implementation Plan 2009-2011,

2010

15 Primary Care Partnerships, Victoria, Victorian Service Coordination Practice Manual 2009

16 Primary Care Partnerships Victoria, Good Practice Guide 2009

17 Primary Care Partnerships, Victoria, Continuous Improvement Framework 2009


SERVICE COORDINATION CONTEXT Effective service system redevelopment work is undertaken in the context of service

coordination and its supporting resources as outlined in the Victorian Service Coordination

Practice Manual (VSCPM)18.

Figure 1-1

CHRONIC DISEASE MANAGEMENT AND CLIENT CONTINUUM OF CARE CONTEXT The Revised Chronic Disease Management Guidelines 200819 indicates that “chronic disease

management (CDM) encompasses the continuum of care from prevention through to treatment

and care management for people with chronic disease”. The diagram below “provides a visual

representation of a schema for CDM, which describes four levels of service intensity for people

with or at risk of chronic and complex needs and the target populations for each level”.

Figure 1-2

18 Primary Care Partnerships, Victoria, Victorian Service Coordination Practice Manual 2009

19 State of Victoria, Victorian Government Department of Human Services, Melbourne, Victoria, Revised Chronic Disease

Management Program Guidelines for Primary Care Partnerships and Primary Health Care Services, October 2008


THE WAGNER MODEL FRAMEWORK The Wagner Model20 also provides a framework that helps to identify the systems changes

(within the primary health care services and across the service system) that are necessary to

improve the coordination of care for people with chronic disease. Taking a systems approach is

important to ensure the delivery of proactive and integrated client centred care.

The model identifies the essential elements of a health care agency or system that encourages

high quality chronic disease care. The elements are interdependent components, building upon

one another. Evidence-based change concepts under each element, in combination, foster

productive interactions between informed clients and health care providers. As its ultimate

goal, the chronic care model envisions an informed, activated client interacting with a

prepared, proactive practice team, resulting in high quality, satisfying encounters and

improved outcomes. 21

Figure 1-3

Source: State of Victoria, Primary and Community Health Branch, Victorian Government Department of Human Services, Melbourne, Victoria,

Revised Chronic Disease Management Program Guidelines for Primary Care Partnerships and Primary Health Care Services, October 2008


Melbourne, Victoria, Revised Chronic Disease Management Program Guidelines for Primary Care Partnerships and Primary Health Care Services, October 2008 21 Ibid.



METHODOLOGY


METHODOLOGY The methodology used in Client Journey Experiential Study comprised the following strategies.

CONDUCT OF A CLIENT SURVEY Clients were surveyed through:

• the conduct of a series of focus groups where clients were invited to complete a specially

developed survey questionnaire

• open group discussion, focussing on the open ended questions contained in the

questionnaire

• a number of people completing the questionnaire individually

• a series of individual client interviews – some face to face and some over the telephone.

The questionnaires used were developed by the PCP SSR Client Journey Working Group and

Questionnaire Development Task Team in Phase 1 of the project. The questionnaires were

based upon the service coordination framework and chronic disease management guidelines

and were pre-tested by clients. The methodology comprised a mix of approaches to support

the participation of clients across a series of “focus group” sessions, a series of face-to-face

interviews with clients in their own homes and telephone interviews. In the conduct of the

study 79 clients participated in using the survey questionnaire. The remaining participants

were engaged in open discussion focussing on open ended questions from the questionnaire.

Clients were asked by the Consultants to provide informed consent to participate in client

survey.

For CALD clients who were non-English speaking, it was indicated that arrangements would be

made for an interpreter as necessary and/or deemed appropriate.

Service providers joined clients in five of the focus groups and one interview, assisting with

completion of questionnaires and explaining the relationships between particular services for

both the consultant and clients.

CONDUCT OF A SERVICE PROVIDER SURVEY A service provider survey was conducted using a questionnaire developed by the PCP SSR

Client Journey Working Group in Phase 1 of the project via Survey Monkey. It was completed

by services/programs within the target sectors and supported by individual service provider

interviews where they were required.

In the undertaking of the service provider surveys service providers were not requested to

conduct actual file audits. They were asked respond to the survey questionnaire with whatever

data and information was available and appropriate. However, given that some service

providers have completed the Department of Health Service Coordination & Integrated Chronic

Disease Management surveys, wherever possible the data provided has been benchmarked

against those.

PROJECT MANAGEMENT The questionnaires were based upon the service coordination framework and chronic disease

management guidelines. They were pre tested by several service providers/clients and subject

to robust project management, planning and reporting processes – using resources such as:

• Initial Project Discussion Paper

• Working Group Terms of Reference (inc. work-plan)


• Project brief

• Task team brief

• Detailed Implementation Plans and Gantt Chart

• Issues Register

• Risk Registers

• Learning’s Register

• Project budget and implementation estimates

• Reporting frameworks (minutes, actions sheets, SSRC /OMC /SDC Implementation Plan

Activity and Outcomes Reports)

• Project Evaluation Framework

A detailed Implementation Plan and Gantt Chart were used to closely monitor and report on

progress and outcomes and to keep the project timelines. Registers were used to identify any

issues and/or risks associated with the project to ensure the appropriate solutions could be

identified and implemented.

Consultants were appointed to organise and conduct the hands on aspects of the study (i.e.

focus groups, surveys etc.), collation, analysis and documenting of the study findings.

The process was supported by implementation of the SSR Communications Strategy – using

the PCP SSR “Focus on Service System Redevelopment” newsletter and a variety of other

communication resources to ensure progress of the project was communicated to PCP

members.

Use of other project information devices to encourage member agency participation and ensure

clarity around project for consultants included:

• Client Journey Project Contact List (for Consultants)

• Client Journey information for Consultant/Expression of interest for quotation

• Letter to service providers from PCP Chair

• Letters of invitation to participate on project Working Group

• Consultants’ Introduction letter to service providers

• Service Provider Information about Client Journey Mapping Process

• Sundry email communications with project information, advice and updates

GOVERNANCE STRUCTURE A strong and flexible governance structure was implemented to facilitate the conduct of the

Client Journey Study consisting of the Service System Redevelopment Committee (SSRC) and

its project/tasks groups reporting through the PCP Operational Management Committee to the

Strategic Directions Committee. The project was conducted via the formation of a Working

Group and task teams to oversight and undertake specific tasks. These were accountable to

the Service System Redevelopment Committee which oversights all SSR work.

PARTICIPANTS The services listed below represent both the service providers who participated in the study

and the services where the participants were drawn from to take part in the study.

SERVICE PROVIDERS AND USERS • Access and Mobility Group

• Age Strong


• Baptcare

• Brotherhood of St Laurence

• Commonwealth Respite and Carelink Centre

• Community Health Frankston

• Community Renewal Frankston North

• Extended Families Australia

• Frankston City Council

• Positive Ageing Group, Frankston City Council

• Frankston City Council-HACC

• Frankston Community Support and Information Centre

• Frankston Senior Citizens

• Greek Women’s Group

• Hastings Indigenous Group

• Impact Support Services

• Mind Australia

• Mornington Community Health

• Mornington Peninsula Shire

• Peninsula Complex Care Program

• Peninsula Health

• Peninsula Health Community Health

• Peninsula Health EICD Program

• Peninsula Health Mental Health

• Peninsula Support Services

• Royal District Nursing Service (RDNS)

• Seagull Day Club – Frankston

• South East CASA

• Villa Maria Southern Community Service

• Wesley Mission Victoria

LIMITATIONS OF THE STUDY The client journey study – the research and resultant outcomes - was subject to several

limitations. For instance, the study did not focus on client knowledge about health

promotion and education services although questions were asked relating to self

management and encouragement to adopt healthy lifestyles. Nor were service providers

asked to provide specific information about the tools used for screening, assessment and

care planning in the questions relating to those service coordination elements. The study

was also subject to the limits of the content of the questionnaires. These could potentially

benefit from further refinement to elicit more precise information.

It was originally intended that the service provider survey would be distributed throughout

the acute and sub-acute sectors. However, a number of the existing questions were

not relevant for these settings. This meant a reworking of the survey was required which

was unfortunately beyond the scope of the existing project resources. PCP and Peninsula

Health's 'Care in Your Community' (CIYC) project staff developed a modified version of the

service provider survey for acute. CIYC trialled the survey within respiratory services. Due

to the small number of responses and the difference in the survey questions these results

are not reflected within the parameters of this study, but the results will be used by CiYC

to inform the Chronic Respiratory Steering Committee.

The study did not include the surveying of GPs or private service providers although GPs

particularly, and private providers where relevant, are mentioned in client responses.



CONSULTATION FINDINGS

The following sections provide a summary of the consolidated consultation findings detailed

under the headings:

• Key Findings

• Themes

• Service Providers survey results

• Clients survey results


KEY FINDINGS There is a significant amount of quantitative and qualitative data within this report expressed

in both written and graph form. Whilst there are finding summaries at the end of each survey

results sections the following are the Key Findings both positive and negative drawn from the

body of the report and supported by data where relevant. Further key findings are also

reflected in the Themes from the Client Groups. These findings have not been prioritised in any

particular order.

CLIENTS � Key client expectations identified were to:

� be able to access the services they require in a reasonable period of time

� receive help and be looked after and be given information appropriate to

their situation

� Key client best experiences of the system were those that:

� involved successful and timely responses to clients’ concerns

� related to particular programs where the leader provided friendly and

appropriate service, tailored for the individual client’s needs.

� Key client worst experiences of the system were those that included:

� slow responses or lack of timeliness in a range of situations

� apparent lack of concern or interest in the individual client

� service providers not taking the time to listen or pay proper concern to the

client needs and issues

� The influence of social and environmental determinants of health and wellbeing and how


important factor to clients feeling supported to adopt and maintain a health lifestyle. The

social support network plays a vital role in enhancing opportunities for living healthier

lifestyles and seeking help from professionals to do so.

� The wide variety of structures from centralised access systems to multiple entry

systems is confusing for clients to navigate although most clients indicated they found

it reasonably easy to get into services when they had needed one in the past twelve

months. However, the length of time to access any service was still of concern to many

others.

� Generally clients indicated that they may receive adequate information about services and

health related issues but there was some degree of difficulty in applying this on a day to

day basis. Health information needs to be targeted and reflective of client needs, abilities

to understand and implement. Terminology in relation to a client’s condition or that used in

the development of care plans should be pertinent and clear to the care providers and

the client which is not always currently the case.

� Clients identified the GP as their first point of contact highlighting the importance of

the role and functions of the GP in primary health care and emphasises the need for

them to be aware of the diverse types of services available to support client care. The

hospital was indicated as clients’ second point of contact which has major implications

for emergency presentations.

� Overall the care planning section demonstrated that those who do receive a care plan

felt very well informed, however, for the majority (58%) they are either not given a

written copy or permission has not been sought for referral both of which are at odds


with a best practice approach. The lack of evidence demonstrated via client comments

that written care plans are not always provided to clients nor client consent sought for

referral is of particular importance.

� Some clients noted that services did not involve carers enough, even though carers took

full time responsibility for meeting the needs of the client outside the service.

� The central role of the GP as seen through the eyes of the client to be the primary health

care provider in coordinating their care is an important issue. Other service providers may

see their service as having the primary care coordination role.

� Recall and review systems embedded in service delivery are core principles of chronic care

evidence based practice. Based upon the study findings review of current practices and

adoption of appropriate systems for followup/recall/review for clients is an area that

requires additional attention at an organisational and practice level.

� Many clients did not see that they actually had a ‘condition’. This raises interesting and

challenging issues about the terms used in consultation with clients. The use of

terminology by health professionals does not necessarily appear to correlate with how

clients viewed their situations. This is a potential indicator of the necessity for regular

review of terminology and its use in day to day service delivery.

� Although there was a very small representative number of clients who responded to the

questionnaire (1%) and also a small number in group discussion who referenced mental

health, timely access to mental health services was an issue from their perspective.

Interestingly, the clients who talked about mental health services perceived them as being

quite separate from other health services.

� Clients identified being listened to and ‘really heard’, treated with decency, courtesy,

respect and have timely follow through as most important to them. Communication

between services and their clients was a major theme throughout the study. The

importance of effective communication between services and their clients especially in

relation to communication of client needs is paramount.

� While many clients believe they are provided with good information when they are new to a

service, they value service providers being able to link them into appropriate services as

part of the follow through role.

SERVICE PROVIDERS � Currently there is a gap in screening and identification of clients with dementia, depression

and anxiety. Service providers are not always aware of whether or not there are

internal processes available to them for identification of clients with dementia,

depression or anxiety. Clients needs beyond the presenting issue do not appear to be

systematically or consistently flagged for their broader needs as evidenced in relation

to clients with dementia, depression or anxiety.

� There is a wide variety of structures from centralised access systems to multiple entry

systems which is confusing for clients to navigate. More work is required to further

integrate and streamline access to services for clients.

� There is evidence of a lack of clarity by service providers around what is Client Focused

Care. Organisations need to develop a clear understanding of what Client Focussed Care

means to them and how they will measure this in their client interactions.


� There is a clear perception that monitoring of client risk at presentation is supported by

consistent practice across service providers regarding effective communication of

timeframes, eligibility and prioritisation across services in accordance with good

practice and may improve client care coordination.

� Whilst nearly all agencies indicated that clients are seen according to need there exists a

wide range of timeframes for practitioners seeing clients from when clients first access

services. This raises questions about service provider communication to referrers regarding

outcomes of referrals given such a variation of timeframes exists.

� Variability exists in what the client can expect from a service in terms of a holistic

assessment process.

� It appears that service providers may view as optional whether or not a service

provider has a choice about implementing good practice around self management

delivery. Consistent and standardised self management practice such as that outlined

in the Active Service Model (ASM-HACC) Guidelines22, calls for processes and tools to

be employed which enable clients self management support at organisational and

practitioner levels to ensure client self management capacity is clearly and accurately

identified.

� Despite the majority of service providers indicating consistent care planning practice there

is still demonstrated variable practice among service providers reflected in the high

percentages of Usually responses to questions relating to care planning. There appears to

be inconsistency between what service providers report in relationship to care planning and

what the findings have demonstrated in the client component of this report. For instance,

from many clients’ perspectives written care plans are not always provided to clients.



perception of most clients who stated that they had not been asked to give consent prior to

sharing their information to other services.

� Clients seeing the GP as central to their first point of call and often as their ‘care

coordinator’ has major implications for appropriate care coordination and streamlined care

between services particularly the need for consistency in feedback and involvement with

G.P.’s in the care planning process by service providers. This is of particular concern for

the management of clients with complex care needs.

� Many service providers are unsure about, or do not know if their organisation has a

monitoring/reminder/recall system. Practice variability which may result in clients

potentially falling through the cracks in the system with pre-existing conditions not being

appropriately managed or supported in the longer term is a challenge.

� Improvements to technology, system wide knowledge and coordination, client specific

referral, communication and coordination were all identified as areas of improvement to the

system by service providers.


2010 and Commonwealth of Australia 2007, Australian Government Department of Health and Aging, National HACC Program Guidelines for the Home and Community Care Program, 2007


� Diverse communication practice exists between service providers and GPs. There are

extensive service provider practice variations between referral timeframes and

transmission of referral acknowledgements. This reinforces the need for the

development of local agreements for referral and for clear feedback mechanisms

agreed upon by services to embed formalised communication processes for service

provider/GP communication.

THEMES FROM CLIENT GROUPS The following themes have been drawn from the questionnaires and from discussions with

clients in both the focus groups and individual interviews. The themes have not been provided

in order of importance. They are all important and attention to each issue is necessary to

engender a robust health system which meets clients’ needs.

The themes can be viewed through the lenses of the personal preferences, expectations and

needs of the client – what they want of the system and the personnel who operate within the

system.

It is useful to note that, although the themes have been described separately to enable the

distinction between issues, an overriding theme has been clearly identified. It relates to

interpersonal communication and the expectation of clients that:

service providers, both as individual practitioners and the service

organisations clients access, are respectfully listening to, hearing and

following through on client issues within reasonable timelines

The support and provision of opportunities for social groupings and occasions also links in with

the communication theme. While transport to access services (this is pertinent to reducing

social isolation for at risk age group – over 65+) and availability of GP services are of critical

importance to clients, these are areas where individual service providers may consider they

have limited influence, and are likely to be issues which need to be addressed more broadly

across the catchment by services holistically dealing with the spectrum of social inclusion

needs in the social context of health23.

It must be noted that the vast majority of those who responded to the questionnaires and

participated in the focus groups believe they are most fortunate with the current service

system, but there are limitations many of which can be addressed.

SERVICE ACCESS Access means different things to different people. There are a variety of matters relating to

‘access’. These have been captured in the following references to access.

ACCESS AND GEOGRAPHICAL AREA

23 Also see the social inclusion findings relating to those at risk of social isolation and the barriers and enablers to groups and individuals being socially connected contained within a study of service providers undertaken by the FMPPCP Integrated

Health Promotion Social Inclusion Working Group in October 2010 – FMPPCP, Social Inclusion Working Group Service Provider

Study, October 2010 – See Appendix 4 for relevant study findings.


While the Frankston / Mornington Peninsula is one Primary Care Partnership geographical area,

people interviewed did not view their individual access to services across the whole catchment

area – they were much more localized in their thinking and service needs, noting close access

to multiple facilities rather than just one main point as important using phrases such as ‘more

services at Rosebud Hospital and locally’.

Many feel they are fortunate with their health and hospital system, but getting to services ‘can

be a problem for many older people, both for obtaining medical care and also for social contact

which is a necessity for well being’.

ACCESS AND TRANSPORT This issue links closely with the social context of health.24 Transport was often not considered

unless someone was unable to drive. For example a survey participant indicated that when

her husband was admitted into Residential Care, a volunteer driver was organised for her to

visit him. She had never previously had any need to drive and now felt quite afraid of the idea

of public transport, especially when he was so ill.

Some people described the linkages within the public transport system as being particularly

cumbersome and often non-existent. One example which demonstrated the difficulty with

public transport within the PCP area was described by a person in Hastings who was offered an

unexpected appointment for a service which has a long waiting list.

“If I need to go to Hastings from Mount Martha, I need to get a bus to

Frankston – but the buses do not interconnect and I can miss the second

bus by 5 minutes and then have to wait ages for the next one. This has

actually prevented me from being able to take up an appointment I was

offered at the last minute when they had a space for a service I had

waiting on a list for ages”.

As mentioned earlier, when public transport is available, some people feel afraid to use it for a

whole range of reasons and one person noted:

“Having someone to help me use public transport would be good.”

Again, in the social context of health, a potential safety issue was raised by a client and is an

example of the need for good practice to be embedded. The client talked about having been

provided by a local service with a motorised scooter which they felt unable to use because

there aren’t footpaths outside the units in which the person lives and the roads are too busy

for them to feel safe even to go down to the local coffee shop

While transport is not specifically a health service, the means to get to services as well as a

means for older people without a car to move around and be able to participate in activities is

an important concern.

ACCESS TO SERVICES Access to services and speed of access to services largely depended on the type of service

required.

24 This is supported by the social inclusion findings relating to those at risk of social isolation and the barriers and enablers to

groups and individuals being socially connected contained within a study of service providers undertaken by the FMPPCP

Integrated Health Promotion Social Inclusion Working Group in October 2010 – FMPPCP, Social Inclusion Working Group

Service Provider Study, October 2010 – See Appendix 4 for relevant study findings.


� “Knowing the system enabled navigation of the service system on behalf of my parent, but I am not sure if this would be possible without

the internal knowledge of the system I have”.

� “My ACAS assessment and CACPS package would never have been possible without the help of a person / partner who knew the systems

to follow you need people who are ‘movers and shakers’ to help you!”

ACCESS TO GP SERVICES All saw the General Practitioner as the key point of entry to health services. The GP was

almost always ticked as the first priority for access. One person noted that:

”Hopefully my GP will be around for a while – sometimes I have to see

one of the other doctors in the surgery if it’s a last minute appointment

and it never works as well”.

In fact, access to a consistent GP is a challenge for many.

“It is very hard to find a doctor in Mornington. I had one person for 40

years, but have had about six since then. They keep leaving me”.

Another noted that most doctors on the Peninsula will not take new patients so they go to a

GP in Frankston.

ACCESS TO TIMELY MENTAL HEALTH SERVICES25 A very small number of clients (1%) talked about their experiences in accessing mental health

services. On initial contact with services clients sometimes felt those services were not as

responsive as they expected when they called which left them at times feeling at a loss

resulting in a degree of frustration. While the examples were small in number some felt

there were limited supports available to assist or talk to a client after-hours. Some of these

clients did not appear to know of any other options when they felt they were in great need

raising issues about their coordination of care. For example, when asked why not contact the

case manager, the response was that:

“I didn’t think that was an area I could ask my case manager to assist

with”.

Generally, clients who talked about mental health services appeared to consider them as quite

separate from any other health services.

LISTENING, NOTICING & FOLLOW UP Civility and respect for older people was a key theme throughout all questionnaires. Listening,

noticing and follow up are pertinent to client centred care. Comments such as the following

reflect the general tenor of desire to be treated with respect:

25 Also see the social inclusion findings relating to those at risk of social isolation and the barriers and enablers to groups and individuals being socially connected contained within a study of service providers undertaken by the FMPPCP Integrated

Health Promotion Social Inclusion Working Group in October 2010 – FMPPCP, Social Inclusion Working Group Service Provider

Study, October 2010 – See Appendix 4 for relevant study findings.


“I want people who will listen to me and make me feel like I am worth

listening to – I mean, listen to what I am saying and really being with

me”.

Expectations were expressed such as these following:

� “I expect services to get back to me when they have said they will – they often don’t!”

� “I expect people to take an active interest and when they say they will do something, they actually do something about it”.

EFFECTIVE COMMUNICATION BETWEEN SERVICES & CLIENTS One theme which was repeated in focus groups throughout the process was the

importance of effective communication between services and their clients especially in

relation to communication of client needs. From the clients perspective this amounted to

being prepared to ask and / or recontact services when told by service providers they will

be put on a waiting list.

One client stated that, following their initial referral, they were placed on a waitlist and

waited for twelve months with some degree of discomfort. This raises the point that not all

people feel confident to assertively communicate their needs. Some people may not have

the language or literacy skills to effectively communicate or recontact a service so they

could potentially miss their opportunity for the required service.

There is an expectation by clients that service providers have an understanding of and skill in

working effectively with older people and people who have a disability of some kind.

“I expect more understanding from the service system and hospitals

about:

• care of people with disabilities

• communication difficulties that people with disabilities sometimes have

• actually talking in appropriate ways to me as a person with a

disability”

CARERS - INVOLVEMENT On occasion, clients noted that services did not involve carers enough, even though carers

took full time responsibility for meeting the needs of clients outside services. This issue was

particularly pertinent when a person had a mental health issue and client confidentiality meant

that carers or family members were not able to find out the most appropriate ways to assist

the client because service providers are bound by confidentiality requirements.

WAITING TIMES AND TIME MANAGEMENT The length of time to access any service was of concern to many with access to both (public)

dentistry and podiatry being the most commonly cited examples with waits of up to four years.

Another concern was the length of time required for repairs to wheelchairs and other aids,

again with many months being described as a waiting time. Waiting times in some GP

practices was also mentioned on a number of occasions as being challenging with some

mentioning waiting times sometimes well beyond their designated appointment times.


SOCIAL GROUPS Social groups are highly valued. Some are provided by Council – often Planned Activity Groups

(PAGs) were mentioned, as was a men’s group for people who had experienced mental health

issues. Clients spoke well of other community service providers which run regular social groups

where clients and case managers interact enthusiastically. People who were part of the Greek

Women’s Senior Citizens Club commented on the importance of their group to them and are

keen to ‘encourage women in particular to ‘come out of their houses and join the group’26. The

Age Strong program was noted by those who enjoyed the program for its social connections as

much as the physical benefits.

CASE MANAGEMENT Those who have case managers generally spoke extremely highly of their service and of how

the case managers had helped them organise their services.

“She always gets back to me quickly and really knows things”.

Highlighting the importance of the case manager’s role and the skill they have in dealing with

their clients, someone noted that:

“……. Now after three different case managers, I know how varied they

can be”.

A person with an intellectual disability felt they had fallen through the system:

“No-one has ever taken me on or case managed me. The State trustees

have never appointed anyone to coordinate my needs. I feel like I have

slipped through the system”.

Although most people did not know whether they have written care plans or case plans, they

thought they “probably had them.” No one who was interviewed commented on the value of

having written care plans, but all noted appreciation of the individual case manager contact

and personal ‘follow through’.

This does however confirm the need to ensure there are systems in place which support case

management.

26 This is also supported by the social inclusion findings relating to those at risk of social isolation and the barriers and

enablers to groups and individuals being socially connected contained within a study of service providers undertaken by the

FMPPCP Integrated Health Promotion Social Inclusion Working Group in October 2010 – FMPPCP, Social Inclusion Working

Group Service Provider Study, October 2010 – See Appendix 4 for relevant study findings.



CLIENTS

SURVEY RESULTS


CLIENTS Across the months of July to September a series of Client groups were conducted. Groups size

varied from small to large, participants alone to those with carers, to groups focused on the

questionnaires and those participating in broader focus group discussion using the open ended

questions contained in the questionnaire.

In addition, a number of in-house and telephone interviews were conducted. In total 149

participants were involved with the completion of 79 questionnaires and substantial qualitative

outcomes.

Date Agency / Group Participants Q’nnaires

Monday July 6th Brotherhood of St Laurence 12 9

Wednesday July 28th Frankston Senior Citizens 15 12

Tuesday August 3rd Seagull Day Club – Frankston 16 15

Wednesday August 4th Baptcare 12 6

Friday August 6th Positive Aging Group, Frankston City Council 4 4

Monday August 9th Access & Mobility Group Blackcamps Road, Somerville 11 8

Monday August 9th Greek Women’s Group, Rye 40 2

Friday August 20th Indigenous Group, Hastings 10 4

Late August / Sept Villa Maria (home visits) - case managed clients 3 3

August Telephone Interviews – Peninsula Support Services 2 2

September Age Strong 24 14

Totals 149 79

Figure 1-4

Of those 79 respondents who completed the questionnaire, the following shows the breakdown

of who actually filled it in:

Figure 1-5

QUESTIONNAIRE & FOCUS GROUP RESPONSES From a total of 149 participants (users/carers/family/friends), questionnaire data was

obtained from 79 Clients who completed a questionnaire. However this represents only

one component of the total information available. Their responses provided the

quantitative and some qualitative data of the total 149 respondents. This report also

contains further narrative providing the qualitative data resulting from discussion by the

remaining 70 study participants involved in focus groups using three open ended questions

contained in the questionnaire:

• What do you expect when you contact a health service for the first time?

• What do you expect of the health service system generally?

• What other suggestions do you have for improvements in the system so that you can

access the services you need?


This section contains the questions asked of clients. The questions were designed to elicit

responses in the areas of prevention, self management, service access, initial contact

experiences, service delivery, care planning, care coordination including referral to other

services and general experiences of the health system. They were broken down into the

following question/information sections reflecting the service coordination and chronic disease

management standards and framework but from a client perspective:

• Client demographics

• About managing their condition

• About getting into services

• About what has been done to manage their condition

• About their experiences of the health system

In the report the questions are sequentially numbered, followed by the graph, data

analysis and any additional information or comments and includes a summary at the end

of each section. In some cases clients have given multiple responses to individual

questions resulting in differences of respondent numbers other than the 79 who completed

questionnaires reflected in the graphs and findings.

The data begins to provide important information with respect to Clients and their attitudes

and experiences in interacting with the health care system. Where appropriate, respondent

comments and additions have been included below graphs to ensure the fullness of responses

has been adequately captured. Data has been de-identified to protect confidences and ensure

the anonymity guaranteed.

To fulfil requirements for confidentiality and anonymity responses that can be linked to

particular respondents and individuals have generally been de-identified throughout the report

with some minor exceptions. Where it has been deemed appropriate and relevant, some

services have been mentioned to ensure the context of any comments about specific services

or organisations is accurately conveyed.

It is important to note that the graphs contained in the client findings relate only to those

participants who completed the questionnaire. Whilst the number of participants prepared to

be respondents has been encouraging, of particular note in the conduct of the client survey

was the high proportion of ‘no response’ (which was difficult to control) across a number of the

demographic and question groups. In some instances the ‘no responses’ accounted for more

than 50% of the participants completing any given survey question.

The disproportionately high level of ‘no responses’ can potentially be attributed to several

factors including:

• a lack of understanding about what the question being asked (especially if they appeared

to be duplicating or similar to previous questions - this could have been an issue with the

questionnaire development) actually could have resulted in clients skipping those

questions which may have been too challenging and going on to those more easily

answered.

• the need to answer questions within the timeframe set for the focus groups may have put

extra pressure on some clients so it could have been easier to answer the questions with

a ‘no response’.

• a perceived or actual lack of relevance of a particular question to the client although this

was clearly not always the case (demographic questions for example). It is also possible

that clients felt they did not need to answer all the questions but only those they felt were

relevant to them or their situation or they felt that the questions may have been too

personal.


• challenges in understanding the language supporting the question, for example the use of

the term ‘care/treatment plan’ was not a term that was relevant to some clients.

Apart from these factors there is no clear explanation as to why so many questions had a ‘no

response’. Further investigation would be necessary to ascertain the reasons why there were

so many ‘no responses’.

As a result of the large number of ‘no responses’ a decision was taken by the Client Journey

Working Group to omit the ‘No response’ from the data analysis represented in the graphs in

this report as it was deemed to overly distort the results and therefore be confusing to

interpret. However, all findings reflected in the graphs clearly state the number of

respondents to each question.

CLIENT DEMOGRAPHICS

1. Age Group:

Figure 1-6

74 of 76 respondents (97%) were in the 50+ age group. Of this group 33% (n=25) were in the 80+ group, 32%

(n=24) in 70-79, and 25% (n=19) in the 60-69 group.

2. Gender:

Figure 1-7 Across those that responded to this question (73 of 79), 70% were female and 30% male.


3. Country of birth:

Figure 1-8

As previously mentioned, out of a total 149 participants (users/carers/family/friends),

questionnaire data from the 79 Clients who completed a questionnaire represents only one

component of the total information available. The Country of Birth information provides an

example of this, whilst only 1% of those completing the survey indicated Greece as their

country of birth, a substantial number of Greek born women participated in the Greek

Women’s group focus group.

4. Are you of Aboriginal or Torres Strait Islander origin?

Figure 1-9

Across those that responded to this question (72 of 79), 4% indicated that they were of Aboriginal or Torres Strait

origin.

5. What is the main language spoken in your home?

Figure 1-10


Respondents did not always choose to answer questions using only the available options.

Whilst providing a more definitive response, at times it has resulted in some answers that were

a combination of more than one option (note English/Greek above).

6. Do you hold a Health Care Card or any Department of Veterans’ Affairs (DVA) entitlement

card?

Figure 1-11

72 responded to this question. 71% (51) indicated that they were holders of a Health Care Card.

7. What is your marital status?

Figure 1-12

77 responded to this question. 43% (n=33) indicated that they were widowed.

8. What are your living arrangements?

Figure 1-13

77 responded to this question. 43% (n=33) indicated that they lived alone.


9. What is your employment status?

Figure 1-14

79 responded to this question. 68% (n=54) indicated that they are retired.

10. What is your postcode?

Postcode Number Suburb

3197 1 Carrum / Patterson Lakes

3198 12 Belvedere Park / Seaford

3199 12 Frankston / Highett

3200 2 Frankston North / Pines Forest

3201 2 Carrum Downs

3911 1 Baxter / Langwarrin South

3912 5 Pearcedale / Somerville

3913 3 Tyabb

3915 6 Hastings / Teurong

3918 1 Bittern

3919 4 Crib Point

3930 3 Mt Eliza / Kunyung

3931 8 Mornington

3934 2 Mt Martha

3938 1 McCrae

3939 5 Boneo / Cape Schank / Fingal / Rosebud / Rosebud Plaza

3941 2 Rye / St Andrews Beach / Tootgarook

Figure 1-15

Although there are defined boundaries for the Frankston/Mornington Peninsula catchment,

those boundaries are not necessarily recognised or important to clients. Servicing clients

in the defined boundaries, locally resourcing people and providing access to services for

clients within their community is important to service providers.

Seeking out services that can be easily accessed or where clients can receive the

treatment they need as soon as possible is of great importance to clients who tended to

view access to services as those that were available to them locally rather than across the

spectrum of services provided across the whole catchment. This was most evident for

clients without access to personal transport as public transport was often not a viable

option for those who are elderly or unwell. This is reflected in client comments throughout

the study process.

******************

ABOUT MANAGING YOUR CONDITION The following questions were designed to identify practices and opportunities relating to clients’

health, how they managed those needs and who did they access to support them in managing their

health.


1. Have you been encouraged by a health professional or someone else to adopt and/or

maintain a healthy lifestyle?

Figure 1-16

Of the 73 respondents to this question, 84% (n=61) indicated that they had been encouraged in a healthy lifestyle by

a variety of sources.

a. If yes, by who?

Figure 1-17

Other • ADASS and AMAP programs / Case Manager / Diabetes Australia / Diabetic Dietician / Instructor /

Naturopath / Nurse (Wirilda Men’s Group) / Program Staff / Seaford Day Club / Self / Specialist /

Tennis Club

A number of respondents indicated multiple responses resulting in 84 responses. Whilst the Other response was most

often indicated 19% (n=16) (see above for examples) the single category receiving the most responses was Health

Professional-GP 14% (n=12) with Partner and Relative the next most common (both with 13% n=11).

If the responses are separated into professional and client social support networks, the social

network responses, i.e. people who are consistently in the clients’ sphere of influence, indicate

33% of clients have been encouraged to adopt healthier lifestyles within the context of their

social networks.


2. Have you been referred to a health professional or community service in the last 12

months?

Figure 1-18

Of 78 respondent, 79% (n=62) had been referred to a health professional or community health service in the

preceding 12months.

a. If so, which one?

Figure 1-19

Other

• Blind group-Seaford /Seagulls / Mordialloc Social Group / CACP / Centre link / Solicitor / State

Trustees / Church Group / Huntington's Association / Legacy / Private health provider (podiatry and

dental)

Specialist

• ENT / Cardiologist / Dermatologist / Neurologist / Ophthalmologist / Orthopaedic surgeon / Plastic

surgeon / Respiratory / RMH / Sport / Thoracic

Community Services

• Age Strong / Seagulls / Baptcare / Council Homecare / Dementia Group-Brotherhood of St Laurence

/ Home Cleaning Service / Home Help

Of 79 respondent, 33% (n=26) had been referred to a General Practitioner, 29% (n=23) had been to a

Community Health (Podiatry) and 19% (n=15) had been to Community Health (Dental). Of the non-single

category response 28% (n=22) had been referred to a Specialist (see above for examples).

3. Do you feel you have been given sufficient information about your condition/illness to

manage it?


Figure 1-20

73 respondents answered with 79% (n=58) indicating that they had received sufficient information to enable them to

manage their illness or condition.

This question was aimed at finding out if the details and information given to clients to help

them manage their health issues/situation was sufficient. However, many comments provided

by clients indicated that they may receive adequate information but there was some degree of

difficulty in applying this on a day to day basis – e.g.

� "medically yes-well informed / practically-NO"

� "oodles of paperwork.”

4. Did you need an interpreter?

Figure 1-21

In keeping with the catchment demographics the bulk of participants in the study did not

require interpreter assistance.

a. If Yes, were you offered an interpreter if you needed one? The one respondent who indicated the need for an interpreter indicated they were not

offered one.

SUMMARY � The influence of social and environmental determinants of health and wellbeing and how


important factor to clients feeling supported to adopt and maintain a health lifestyle. For

example the majority of those participating in the focus groups talked about

encouragement to adopt a healthy lifestyle including giving up smoking and undertaking

more exercise – this encouragement came from a range of partners, social networks and

health professionals. The social support network plays a vital role in enhancing

opportunities for living healthier lifestyles and seeking help from professionals to do so.


� Many clients did not see that they actually had a ‘condition’. This raises interesting and challenging

issues about the terms used in consultation with clients. The use of terminology by health

professionals does not necessarily appear to correlate with how clients viewed their situations.

This is a potential indicator of the necessity for regular review of terminology and its use in day to

day service delivery.

� Generally clients indicated that they may receive adequate information but there was some

degree of difficulty in applying this on a day to day basis. Health information needs to be

targeted and reflective of client needs, abilities to understand and implement.

� Although there were quite a few people from CALD backgrounds who participated in the

focus groups, most appeared to have adequate English for day to day discussion. Perhaps

this explains the fact that only one person said they required an interpreter reflecting the

general CALD demographics of the catchment. On the other hand, a number in the focus

groups commented to the consultant about concerns they had in understanding the service

provider, especially when that person has a strong accent. This point was repeated

frequently and although not represented in the questions, it was an issue of concern for

many Focus group participants.

******************

ABOUT GETTING INTO SERVICES The following questions specifically relate to service access and initial contact.

5. When you need to use health services where do you go to as a first priority?

Respondents identified multiple sources when needing to access health services.

First Priority

Figure 1-22

Other Brotherhood of St Laurence 3

Depends on Circumstances 1

Case Manager 1

Koori Kitchen connection 1

wife-nurse 1

Wirilda men’s group 1

Of the 84 responses received 67% (n=56) indicated that they go to their General Practitioner first when accessing a

health service. In addition General Practitioner was included in multiple other responses along with Hospital/Local

Council/Pharmacist. Other (examples above) at 10% (n=8) and Pharmacist 8% (n=7) were the next most

accessed.


The responses clearly indicate that the GP is the first and primary contact when needing to

access services. However it also highlights the complexity for GPs in knowing or being familiar

with the multiplicity of services available within the catchment and specific to their client

needs.

Also important is the role of the pharmacist as a first point of contact and in the day to day

support of their client who is managing their health condition.

Second Priority

Figure 1-23

Other Family 1

Other 1

Of the 44 responses which indicated services accessed as a second priority 32% (n=14) indicated that they accessed

Hospital, General Practitioner (25%, n=11) and Pharmacist (20%, n=9).

Hospitals are viewed as a secondary priority access point for clients to receive services placing

further strain on hospital ED admission resources.

Third Priority

Figure 1-24

Other Family 1

Nurse-On-Call 1


Of the 26 responses who indicated a third priority 46% (n=12) use Pharmacist with Community Health (19%, n=5)

and Hospital (15%, n=4) the next most utilised.

This highlights the importance of the community link and access to pharmacists and the role

they have in client care and the need for there to be closer linkages with these private

community services.

Fourth Priority

Figure 1-25

Other

AMAP 1

Brotherhood of St Laurence 1

Of the 20 responses who indicated a fourth priority 30% (n=6) indicated that they used Community Health, 25%

(n=5) indicated Hospital as the next option with Pharmacist (15%, n=3) the next most utilised.

Fifth Priority

Figure 1-26

Other

Nurse-on-Call 1

Other 1

Finally, of the 13 respondents who indicated a fifth preference the Local Council was the most common (65%, n=8).


6. If you needed to go to a service (or services) in the last 12 months how easy was it to

access?

Figure 1-27

69 responses were received, the result for ease of accessing a service in the previous 12 months was the same for

Very easy or Easy at 38% (n-=26).

7. Over the last 12 months have you attended a health or community service?

Figure 1-28

Of the 69 responses 60 (87%) had attended a health or community service during the preceding 12months.

If so which

0%

5%

10%

15%

20%

25%

0

5

10

15

20

25

30

35

40

45

50

% o

f re

spo

nd

en

ts

no

. o

f re

spo

nd

en

ts

no. of respondents

% of respondents

Figure 1-29


Other Specialist Baptcare 1 Cardiologist

Brotherhood of St Laurence 1 Dentist

Meals-On-Wheels 1 Dermatologist

Other 2 Endocrinologist

Private Health Practititioner 4 ENT

Villa Maria 1 Gastroenterologist

Community Health Sector Huntington’s Specialist

Age Strong 3 Neurologist

Other 1 Opthalmologist

Respite 1 Renal

Community Services Other Sports

Brotherhood of St Laurence 1 Thoracic

Mental Health 1 Urologist

MEPAC 1 Vascular

Multiple services were attended by clients within the last 12 months as evidenced by the

multiplicity of services indicated in the graph and table which highlights the importance of

the client attendance at GPs services and also Community Health within that period.

8. If you have used a service in the last 12 months, from the time you contacted the service

how long did it take to receive help?

Figure 1-30

Of the 57 responses 32% (n=18) indicated that they had received help on the Same day they contacted the

service, 26% (n=15) received assistance within 2-3 days. Consolidating, 58% received help within 2-3 days at

the most of requesting it.

However, there still appear to be challenges accessing podiatry and dental services within

a reasonable time period. Issues regarding GP accessibility were also indicated by clients.

For example:

� “GP only there 2 days/week, hard to get appointment but tells me to ring other Dr's there if an urgent problem.”

9. If you have used a service in the last 12 months, were you offered information when you first

used the service?

Information is considered to be either written or verbal information, may be general,

health or service related or useful instructions to help navigate the system and understand

eligibility for accessing services.


Figure 1-31

71% (n=42) indicated that they were offered information on first contacting the service.

a. Was this information clear and accurate?

Figure 1-32

Of the 38 responses to the clarity and accuracy of the information provided, 39% (n=15) answered that the

information provided it was Excellent or Very good (42 %, (n=16).

b. Was this information helpful/useful?

Figure 1-33

There were 38 responses to the helpfulness/usefulness of the information provided, 55% (n=21) answered that the

information provided it was helpful/useful All of the time or Most of the time (34 %, (n=13).

c. Describe what was useful and what was not useful?

The responses indicated that there was a mix of verbal and written information provided to

clients. The information clients were given was not only regarding their condition but the


system they were using and is reflective of various segments of the health & community

service sector. For example:

� “advised when I would be able to access services-cost etc.”

� “information appropriate and necessary for my condition.”

� “I work in Community Health I have been well able to navigate the service system in terms of meeting my mother’s needs. I am not

sure I would be so confident were I not in Comm Health.”

� “GP gave information and explained everything.”

� “immediate, helpful for surgery.”

Further investigation into the actual helpfulness/usefulness of specific written health

information would be needed to ascertain a more robust response to this question.

SUMMARY � The vast majority of clients indicated that they access their General Practitioner as a first

priority. Many also accessed hospitals and Pharmacists. The fact that GP’s, hospitals

and pharmacists are the priority contact points for clients seeking help requires these

providers to be a rich source of information about a whole raft of services. This highlights

the importance of the availability of up to date service provider information through

service directories and the embedding of consistent service provider practice in the use

of service directories.

� Most clients found it reasonably easy to get into services when they had needed one in

the past twelve months – and usually within 2 – 3 days of the request. It should be

noted too, that verbal comments by participants suggested a high degree of satisfaction

with the speed of response for emergency situations.

� There is some contradiction between the approximate 90% of clients who responded to

questions about clarity and timeliness of information provided when people first use a

service. They indicated that they believed it was clear, helpful and timely yet also

indicated there was some degree of difficulty in applying this information on a day to day

basis.

******************

ABOUT WHAT HAS BEEN DONE TO HELP YOU MANAGE YOUR

CONDITION The following questions were designed to identify practices and opportunities relating to

care planning once the clients had accessed services. They also try to ascertain the

degree of engagement of clients in the development of, and knowledge about, their

individual care and to determine the clients’ understanding of their care/treatment plans -

who is involved when there are multiple service providers caring for the client.


10. Have you been encouraged to adopt and/or maintain a healthy lifestyle?

Figure 1-34

64 respondents answered this question with 86% (n=55) indicating that they had been encouraged to adopt or

maintain a healthy lifestyle.

11. Do you have a treatment/care plan(s)?

Figure 1-35

Out of 75 responses, whilst 63% (n=47) indicated Yes, they did have a treatment or care plan, 37% (n=28)

responded No or were Unsure.

37% of clients who were either unsure about or did not have treatment/care plans is indicative

of an important care planning issue, i.e. that processes supporting communication and client

engagement in the process need to be addressed.


a. If Yes, do you have a written copy of your treatment/care plan(s)?

Figure 1-36

Of the 47 respondents who indicated that they did have a care plan only 58% (n=27) responded that they did

not have a written copy.

This raises questions regarding the client’s involvement in the treatment plan as this

demonstrates that the majority of people don’t receive a written copy. It should be noted

however, that this does not necessarily equate with there not being a care plan developed by

the service provider, only that the client has not received a written copy.

12. How many treatment/care plans do you have if you have more than 1?

0

1

2

3

4

5

6

7

8

9

10

number of care plans

no

. o

f re

spo

nd

en

ts

no. of respondents 5 2 1 1 9

% of respondents 6% 3% 1% 1% 11%

2 3 4 5 Unsure

Figure 1-37 One consumer had 5 care plans which potentially indicates a lack of communication between service providers

and lack of streamlined care for the client.


13. Have you been actively involved in developing your treatment/care plan(s)?

Figure 1-38

Of 49 respondents, 24% (n=19) indicated that they were actively Very involved all of the time or 22% (n=17)

Most of the time in developing their treatment/care plan.

A potential issue is the finding that 10% of clients indicated they were “told’ what to do. This

becomes an issue about delivering client centred care. This would need further investigation to

determine the actual process these ‘told’ clients went through.

14. Do you have more than one health need that requires several different services?

Figure 1-39

Of 60 respondents 58% (n=35) indicated that they required access to several different services due to the fact that

they had had more than one health need.


15. Have you been referred to any other service or specialist?

Figure 1-40

Of 61 respondents 57% (n=35) had been referred to other services or specialists.

The high percentage of referral to other services and specialist indicates the need for

appropriate referral and feedback practices/pathways among service providers.

16. Do you have someone coordinating your care?

Figure 1-41

Of 62 respondents 68% (n=42) have someone coordinating their care.

a. If yes, then please indicate who coordinates your care.

Figure 1-42


70 responses were received to this question with a number of respondents providing multiple selections. General

Practitioners 37% (n=26) were identified as the most common care coordinators with Case Manager/Worker the

next most common (26%,n=18).

Once again this highlights the central role of the GP as seen through the eyes of the client to

be the primary health care provider in coordinating their care.

17. Are you clear about who is doing what?

Figure 1-43

Of the 60 respondents to this question, 60% (n=36) were Very clear about who was doing what in coordinating their

care.

This is a positive reflection that clients who have someone coordinating their care feel “very

clear” about roles and responsibilities, i.e. who is doing what.

18. Are you normally asked to give your consent to share your personal information with other

service providers?

Figure 1-44

52% (n=33) of the 63 responses to this question indicated that they were not normally asked to give consent prior to

sharing of their information with other service providers.

This is in stark contrast to the result indicated in question 50 in the service provider survey

where 96.2% of service providers said they normally ask for their client’s consent to allow their

service to access and share the client’s personal details and health information with other

service providers.


This response is at odds with current best practice in privacy & confidentiality27. It also

reinforces questions regarding clients’ involvement in the development of their treatment plans

and their understanding of what they constitute. This is also reflected in the responses to

Question 11a “…..do you have a written copy of your treatment/care plan(s)?” which shows

that 58% No responses indicating that the majority of people don’t receive a written copy. 28

19. Have you been contacted by your service provider or practitioner for appointments/review?

Figure 1-45

Of the 59 responses to this question, 34% (n=20) that they felt that their service provider (practitioner) contacted

them All of the time for follow up appointments or review. Of note, the next most common response indicated that

this occurred None of the time 25% (n=15).

Planned structured care is fundamental to chronic disease management. In terms of

system support for clients managing chronic disease, including multiple co morbidities, a

lack of recall and review appointments 25% none of the time is a concern.

27 Primary Care Partnerships, Victoria, Victorian Service Coordination Practice Manual 2009 - Pages 8 &12

� “Consent to share consumer information - Privacy legislation requires the protection of an individual’s personal information and their right to decide how the information is used or disclosed (shared) with others. Due to the transfer of a consumer’s information, as part of the referral process, it is necessary to obtain the consent of consumers prior to the disclosure of information for any secondary purpose. The primary purpose is the purpose for which the information was originally provided, while the secondary purpose is any additional information, such as information identified in the Initial Needs Identification process, which is not directly related to the consumer’s original request. See: www.health.vic.gov.au/hsc/infosheets/disclosure.pdf “

� The service provider collects information in a sensitive manner, with particular regard to cultural requirements, language issues, communication and cognition needs, privacy and confidentiality, and where practical, anonymity –

� The service provider obtains informed consent before sharing information with another service provider for Initial Needs Identification, Assessment, Care Planning or service delivery

� The service provider shares information without consent in accordance with the Health Records Act, and other requirements such as Duty of Care, Mandatory Reporting and information sharing provisions”

28Primary Care Partnerships, Victoria, Continuous Improvement Framework 2009, Page 15, Criterion 6.13 “Consumers are

provided with a copy of their care plan, where appropriate, in a format which they can easily understand”


20. Were you offered information/support to help you manage your condition/situation?

Figure 1-46

Of the 59 responses to this question the majority 46% (n=27) felt that they were offered information or support to help

them manage their situation.

The client feeling supported by the service provider is central to their engagement with the

service. The 46% all of the time response is a positive reflection that service providers are

offering information and support to clients to help them manage their health conditions and

situations. However, there is room for improvement as 38% of the responses indicated clients

has information and support from the service provider some or none of the time.

21. Are you satisfied that your health needs are coordinated between service providers?

Figure 1-47

A clear majority of the 61 responses to this question, indicated that they were Very satisfied (52%,n=32) or Mostly

satisfied (39%,n=24) with the coordination of their health needs between providers.

91% of the respondents noted satisfaction that their health needs are coordinated

between service providers. However, during discussion some clients raised concerns about

a perceived delineation between the case management received for general health issues

and those for mental health issues.


SUMMARY � The responses relating to the Treatment/Care Plans questions are of particular

importance as the questionnaire responses appear at odds with some of the discussions.

63% (of 75 responses) have noted that they have a treatment or care plan whereas the

comments made while completing the questionnaire suggested that people did not know

whether or not they had one. A number said that they supposed their GP would have a

plan. Of particular importance is that 58% said they do not have a written copy of their

plan. Overall the care planning section demonstrated that those who do receive a care

plan felt very well informed, however, for the majority they are either not given a written

copy or consent has not been sought for referral both of which are at odds with a best

practice approach.

� It is possible that the terms ‘Care or Treatment Plan’ are not meaningful for many clients

or it may be that the Plans either orally or in written form are often more pertinent to

the service providers than the client. Appropriate terminology is important to ensure

clarity for clients about what they are being told or given in relation to treatment/care

plans.

� Care coordination is another area of confusion. It is interesting that 37% identified a

General Practitioner as a Care Coordinator. Where people have a specific Case Manager

or Case Worker, the issue is clearer for clients, with a number of people noting the role

of case manager very highly.

� Although 91% of the respondents noted satisfaction that their health needs are

coordinated between service providers, some clients raised concerns about a perceived

delineation between the case management received for general health issues and those

for mental health issues. This identifies the need for greater focus on integration of

mental health services in primary care.

� The central role of the GP as seen through the eyes of the client to be the primary health

care provider in coordinating their care is an important issue. Other service providers may

see their service as having the primary care coordination role. Understanding and agreement

about roles and responsibilities of care coordinators, GPs, key workers for client care

coordination among multiple services is paramount. Clients who have someone coordinating

their care feel “very clear” about roles and responsibilities.

� Planned structured care is fundamental to chronic disease management to provide better

support for clients managing chronic disease, including multiple co morbidities. A lack of

recall and review appointments 25% of the time is a concern. Review of current practices and

adoption of appropriate systems for followup/recall/review for clients is an area that requires

additional attention at an organisational and practice level.

******************

ABOUT YOUR EXPERIENCE OF THE HEALTH SYSTEM This section comprises the responses to several open ended questions providing

opportunity for broad discussion and feedback about client’s perceptions and their

experiences of the health system.


22. Thinking about the last 12 months, how would you describe your experience of the

health system?

Figure 1-48

A clear majority of the 65 responses to this question, indicated that they were satisfied (Very satisfied (45%,n=29) or

Mostly satisfied (45%,n=29) with their experience of the health care system over the past 12 months. Whilst those

that indicated a dissatisfaction or unhappiness represented a small number, their stories are compelling and are

somewhat reflected in the themes and client experience sections.

A differential exists between the clients’ expectations and experience of care as to what

service providers ‘know’ are the clients’ rights. For example, the 52% (n=33) of the 63

responses to the question “are you normally asked to give your consent to share your

personal information with other service providers?” indicated that they were not normally

asked to give consent prior to sharing of their information which is fundamental to good

practice and in accordance with legislation (Health Records Act and other requirements).

Clients would not necessary be fully aware of those rights without them being clearly

communicated. This is one example only but the conclusion could be drawn that client

satisfaction with their experience of the health system is based on less than absolute

knowledge and understanding of how the system should be operating or the standards it is

required to meet. This raises some interesting questions about perceptions versus

practice.

23. Thinking about the last 12 months, please describe your best and worst experience

of the health system?

Overall, responses to this question generally indicated that ‘best’ experiences were those that:

• involved successful and timely responses to clients’ concerns

• related to particular programs where the leader provided friendly and appropriate service,

tailored for the individual client’s needs.

Not surprisingly perhaps, many of the ‘worst’ experiences people described were about:

• slow responses or lack of timeliness in a range of situations

• apparent lack of concern or interest in the individual client

• service providers not taking the time to listen or pay proper concern to the client needs

and issues

Following are typical examples of clients’ responses to this question. They have been

categorised for ease of understanding.


SUCCESSFUL AND TIMELY RESPONSES Highlighted examples were responses in emergency situations when people were

experiencing life threatening issues. Acute services and prompt referral to specialists who

managed the clients’ health concern was frequently mentioned in this situation. Similarly,

the swiftness of response of the Ambulance Service and ‘going to hospital by ambulance’

were best experiences noted in at least three responses.

A prompt response from particular individuals often provided a best experience for people

who used such phrases as:

� ‘an intelligent and helpful pharmacist’

� ‘speedy response of eye doctor when I was diagnosed with

macular degeneration’

� ‘prompt investigation of angina pain resulting in insertion of a

stent’.

TAILORED PROGRAMS AND SERVICES MEPAC contact was considered excellent by a number of respondents who again noted the

timely response, and also commented on staff ‘knowing the client’ and being reliable.

The Diabetes Support Group received a special mention as a best experience and others

commented they were very pleased with all rehabilitation services they had experienced –

sometimes in a facility and some with exercises from the Community Health Service which

they did at home.

Some mentioned water aerobics as being good. A program conducted for the Koori

population was described as very positive, specifically noting that the physiotherapy Koori

program and the Koori Kitchen are ‘fabulous’! Another person commented on the value of

a particular Hastings GP with an excellent knowledge of Aboriginal people and experience

in working with them both locally and in other parts of Australia.

Some individualised services organised for one person by a case manager were very

important for them:

“Getting a hospital bed at home which raises and lowers at the push

of a button and moving into my Department of Housing unit have both

been vital for me”

Another commented on their experience as been mainly a positive one with good support

from specific services.

“Although my daughter has had to prompt things to happen

occasionally, much has been good. A woman from the Rehab service

instigated an ACAS assessment, talked through all the services and

gave me a book with a listing of places where I might live.”

WAITING TIMES Many ‘worst’ experiences can be summed up around the issue of length of time waiting for

some services. These experiences were not confined to a single service. Examples of long

and inappropriate waiting times included waiting for some aids and for their repair – e.g.,


two different people talked of being referred for wheelchair repairs. The electric

wheelchair, which was one person’s only means of mobility, had been notified some

months earlier that it would be available, yet was still awaited six months later.

Another person described follow up not being provided after surgery and when a complaint

was made the appointment provided required a four month wait.

Waiting times in GP practices was also mentioned on a number of occasions as challenging

with some clients sometimes experiencing lengthy delays well beyond their designated

appointment times. Still others noted the time to receive services from public dentistry –

sometimes three or four years – as the worst experience, even though others noted that

they were pleased with the dentistry service when they received it.

ACCESSING MENTAL HEALTH SERVICES Mental health services provided a diverse experience for a number of people with a focus

on the ‘lesser’ experience by a small number of people (1% of respondents). Some

described situations where they felt there were few supports available to assist or talk to a

client after-hours, while others described situations where concerned carer/family

members considered they did not necessarily have adequate access to services or

appropriate response to what they felt they needed from service providers resulting in a

degree of frustration. While these examples were very small in number, the degree of

distress caused in some cases would seem to prompt further exploration of processes

around after-hours availability of mental health services and links with other health

services.

PALLIATIVE CARE The experience with the Palliative Care service comprised a sad but very positive

experience with the service system for a number of respondents who made comments

such as – ”they really care”.

In some cases, reaching the palliative care service stage provided a relief for family carers

who on occasion, described being ”swamped with people” who were providing services at

home, but did not appear coordinated in any way. This is described in the Case Story

below.

ACUTE SERVICES The experience of clients in emergency and hospital settings was referred to frequently by

clients. Themed comments of clients’ lesser experiences tended to focus on the care

coordination between and within services, and (consistent with other clients experiences of

other services) being treated in a timely and responsive manner. When respondents had

experienced emergency situations in which they felt their needs were met they described

acute services very positively.

A CASE STORY The following brief case example regarding ‘the journey’ demonstrates the complexity of

services from the perspective of a client who is both in a shocked state and also not

familiar with the service system. This case study highlights the following:

• the importance of discussing roles and responsibilities with clients

• discussing what to expect from the service

• coordinating care appropriately

• the importance of having a “whole of client” approach not just what “your” service

does


“My partner was diagnosed with cancer. It was an awful shock at

diagnosis. The hospital gave me a card and people turned up at home,

but I didn’t know who was around for what. I really needed someone

specific who knew me and I could talk to. For months, no-one came to

talk to me to find out how I was going. I was totally lost, but no-one

had any sort of overview.

We needed to travel from Rosebud to Frankston for treatment.

Neither of us was able to drive so we asked friends to drive us. After

some time, the staff at Frankston Private where chemotherapy was

provided were able to organise volunteer drivers ‘who were

marvellous. When my partner became sicker we had access to District

Nurses who put us onto Palliative Care which was really very helpful.

Before Palliative Care we had a whole range of people turn up – from

Mornington. I was like a lamb lost in the woods. After my partner got

really sick, I got fabulous help from District Nurses and from Rosebud

District Hospital.”

******************


CLIENT EXPECTATIONS

24. What do you expect when you contact a health service for the first time?

Figure 1-49

Most respondents were seeking (and expected) some form of Help (13%, n=9) when contacting an agency.

Most respondents were seeking Information (10%, n=7), expected to find someone to Listen (10%,n=7) to

them and expected Timely (10%, n=7) response with respect to treatment, information or waiting times.

This question provided a wealth of information and commentary. Answers were taken and

where possible, categorised into general response concepts within the graph. Whilst not

always possible to fully capture the full meaning of any given respondents comments in

allocation to a group, to try to lessen the impact of this:

• the range of concepts has been kept as broad as possible

• most answers had a number of components which have been broken down and

included across multiple concepts expressed in the graphs

Appendix One contains a summary of the responses indicated for this question.


25. What do you expect of the health service system generally?

Figure 1-50

For the majority of respondents (22%, n=14) Timely access to treatment, information and reasonable waiting time

was most important with the next most common expectation being that they expected Help (to be looked after) (16%,

n=10) from the system.

As with the previous, this question also provided a wealth of information and commentary.

As before answers were taken and where possible, categorised into general response

concepts Whilst not always possible to fully capture the full meaning of a respondents

comments in allocation to a group, to try to lessen the impact of this:

• the range of concepts has been kept as broad as possible

• most answer had a number of components which have been broken down and

included across multiple concepts

Key client expectations identified were to:

• be able to access the services they require in a reasonable period of time

• receive help and be looked after and be given information appropriate to their

situation

Also clients indicated they wish to be treated with respect, decency and politeness.

“All I hope for is to live a healthy life like an old car. Treated with

respect. Lots worse off than me. Lots of places do need a better

health system. I do think the public system is very good”.

“I expect nothing generally. I am responsible for me but they are

responsible to respond to me and my requests / needs. If they have

a system they should follow it”

“To be treated as an intelligent person, not stupid, just because I'm

old”.

Appendix One provides a further summary of the responses to this question.


26. What other suggestions do you have for improvements in the system so that you can

access the services you need?

Whilst other answers have been analysed and summarised, the authors felt that it was

worthwhile leaving some of the comments made by clients to give a general feel for what

they considered to be improvements in the system. These have not been categorised –

there are very general comments and some that are more specific - but provide ‘food for

thought’ highlighting what is important to individual clients.

� “Accessibility / Reliability / Consideration.”

� “All organisations need client / advocacy groups to communicate their needs directly. Make support of disabled a 'Right'.”

� “As a privately insured person I am satisfied with access to health services.”

� “Better exchange of ideas”

� “Case Managers to organise for us that which we have difficulties and that which we don't have knowledge of.”

� “Civility and respect for the elderly and good time frames for access-better provisions for weekend access. Close access to multi facilities in lieu of one main point. More services at

Rosebud Hospital and locally.”

� “Cut down waiting times in doctor's surgeries.”

� “Emergency services from private hospitals in this area Frankston / Mornington.”

� “Encourage patients to come out of their houses………….”29

� “Transport.”30

� “Everything is fine for me at present.”

� “I feel we are lucky with our hospital system. Transport can be a problem for many older people, both for obtaining medical care and also for social contact, a necessity for well

being.”31

� “I have an Intellectual Disability and no-one has ever taken me on or case managed me. The State trustees have never appointed anyone to co-ordinate my needs…………...”

� “I have had success with all services that I have needed.”

� “Less waiting time for public patients.”

� “More care, compassion and accurate appraisals.”

� “More dedicated follow-ups and time management issues.”

29 This is supported by the social inclusion findings relating to those at risk of social isolation and the barriers and enablers to groups and individuals being socially connected contained within a study of service providers undertaken by the FMPPCP Integrated Health Promotion Social Inclusion Working Group in October 2010 – FMPPCP, Social Inclusion Working Group Service Provider Study, October 2010 – See Appendix 4 for relevant study findings.

30 Ibid.

31 Ibid.


� “Our time is valuable also.”

� “More information from Government sources re. telephone numbers / access to facilities.”

� “More people like my Case Manager.”

� “More staff-they need more people as drivers and assistants in all areas to relieve some of the pressure. If working in Aboriginal Community patients are likely to contact across 24

hrs.”

� “Most doctors on Peninsula won't take new patients.”

� “My health is generally good so have very little need to access services, but when I have had to, have been happy with service. Biggest problem on Peninsula is too few doctors

and too few doctors who bulk bill.”

� “Not really-If giving explanations do it in a language which I can understand. Don't use long words which don’t make sense.”

� “Rehabilitation needs to happen as soon as a person leaves hospital and returns home.”

� “Specialists talking to one another.”

� “……………………take an active interest.”

******************



SERVICE PROVIDER

SURVEY RESULTS


SERVICE PROVIDERS FMPPCP service providers were invited by the Service System Redevelopment (SSR) Client

Journey Working Group to participate in the survey developed by the Client Journey Working

Group and the Questionnaire Development Task Team.

A total of 87 online survey responses were submitted by service providers giving a great

breadth of response from across the 35 member organisations of the FMPPCP. Of the 87

responses 22 provided extensive in-depth and diverse information. As anticipated, major

respondent groups are reflective of the larger service providers.

The online survey results were collated and presented to fulfil a project objective to develop a

base of data upon which to continue further service development, coordination and planning.

As with the Client survey, to fulfil requirements for confidentiality and anonymity responses

that can be linked to particular respondents and individuals have generally been de-identified

throughout the report with some minor exceptions. Where it has been deemed appropriate

and relevant, some services have been mentioned to ensure the context of any comments

relating to a specific service or organisation is accurately conveyed.

SURVEY RESULTS This section contains the data, graphs and information mapped to the relevant survey

questions asked on Survey Monkey. It is broken down into the following question/information

categories reflecting the service coordination and chronic disease management standards and

framework:

• Service provider demographics

o Name of organisation – number of responses submitting

o Number of multiple response information

o Program/service area response relates to

o Role of person responding to survey

o Agency type

o Agency catchment

• Service provider client demographics

o Agency client group

o Client age demographic/life stage

• About our structures & processes

• Service accessibility

• Assessment & Care Coordination

• Referral & feedback

• Client pathway information

Where applicable and appropriate, comparison between this study and the Department of

Health Service Coordination/ICDM 2009 survey results for Frankston Mornington Peninsula has

been made and included in this report. However, we acknowledge that this may not be a true

comparative given the differences in the framing of the questions, the smaller survey sample

and agency type involved in the Department of Health survey. The data collected by the

Department is based primarily upon file audit and provides some robustness for data

comparison.

It is important to note that the graphs contained in the service provider findings relate

only to those questions completed in the questionnaire by service providers. As with the


client survey result, of note in the conduct of the service provider survey was also a high

proportion of ‘No responses’ across the broad spectrum of service provider agency types

participating in the process. Also it needs to be remembered, as previously mentioned, that

service providers were not asked to conduct a specific file audit for this study (although some

may have chosen to do so) to support the data/information collection process. However,

extensive in-depth and diverse information was provided by many agencies as indicated. The

‘no responses’ might potentially be attributed to several factors including:

• the high probability that actual hard data was not available to adequately answer

some questions. Apart from mandated data collection for reporting generally more

fully developed data collection/availability is still an issue for many service providers.

• a lack of understanding about what the question being asked actually meant resulting in

service providers skipping those questions which may have been too challenging and

going on to those more readily answered.

• time constraints from heavy workloads putting pressure on individuals responding on

behalf of services to complete the survey in quickest possible time thereby missing some

of the questions either by choice or default

• a perceived or actual lack of relevance of a particular question to the service provider

which has legitimacy as some questions would not be relevant to every sector/type of

service provider. Service providers would only answer the questions they felt were

relevant to them or their service situation.

• challenges in understanding the questions, especially if they appeared to be duplicating or

similar to previous questions (this could have been an issue with the questionnaire

development).

• technical issues experienced in accessing and using Survey Monkey (some were in fact

reported and also identified by the Consultants).

Apart from these factors there is no clear explanation as to why so many questions had a ‘no

response’. Further investigation would be necessary to ascertain the reasons why there were

many ‘no responses’.

******************


GENERAL AGENCY DEMOGRAPHICS

1. Name of Your Organisation.

Responses were received from the following service providers. Several organisations

submitted multiple responses indicated in the table below.

Organisation Number of

responses

Baptcare 1

Brotherhood of St Laurence 2

Commonwealth Respite and Carelink Centre 2

Community Renewal-Frankston North 1

Extended Families Australia 2

Home and Community Care

(HACC) 1 Frankston City

Council Frankston City Council 4

Frankston Community Support and Information Centre 2

Impact Support Services 1

Mind Australia 1

Mornington Peninsula Shire 1

Peninsula GP Network 1

Peninsula Health 33

Community Health 13

Early Intervention in Chronic

Disease (EICD) 1

Mental Health 3

Peninsula Health

Complex Care 3

Peninsula Support Services 3

Royal District Nursing Service (RDNS) 3

South East Centre Against Sexual Assault (CASA) 1

Villa Maria Southern Community Service 1

Wesley Mission Victoria 1

Not identified 6

Total Responses 87 Figure 1-51


2. We are submitting multiple responses.

Figure 1-52

From the overall respondent number of 87, 86 answered this question with 51 respondents (59.3%) indicating that

they had provided multiple responses from their organisation.

3. How many responses are you submitting from your organisation?

The number of responses varied from 1 to 8 per organisation.

4. Name of the Program this response relates to:

• ACCESS

• Aged and Disability Services (HACC)

• Aged and Disability Services

• Aged Persons Mental Health Team

• Brotherhood Community Care (Southern)

• Carer Support

• Child, Family and Community

• Children's Services / Health Promotion

• Chronic disease

• Client Journey Experience

• Client Services

• Community Aged Care Packages

• Community Health

• Community Health-Counselling service,

• Community Mental Health

• Community Packages Program

o Community Aged Care Package (CACP)

o Extended Aged Care at Home (EACH)

o Extended Aged Care at Home Dementia Package (EACHD)

• Community Rehabilitation program

• Community Renewal Frankston North

• Complex Care

• Dietetics - Community Health

• Disability Mental Health and Young Carers

• Early Intervention Chronic Disease (EICD)

• Falls Prevention Service

• General Service

• Health Promotion


• Mental Health Program-Frankston

• Mental Health Service

• Peninsula Complex Care Program

• Peninsula Post-Acute Care

• Planned Activity Group

• Primary Mental Health

• Psychosocial Rehabilitation Program

• RAD and ROSS Teams

• Respite Options

• Rosewood House

o ROSS Program

o Seaford Program

o South Eastern Centre Against Sexual Assault (SECASA) (victim service)

o Social Work

o The Cognition Service

o Youth Health Promotion initiatives

5. How would you describe your role in the program/organisation?

Figure 1-53

Other

Care Coordinator / Community Development worker / Coordinator / Health Care Coordinator / Project

worker, Social worker / Assessment Officer, Special project worker / Team Leader.

From the overall respondent number of 87, 86 answered this question with 33 respondents (38.4%) identifying

themselves as being in a Middle Management position and 18 respondents (20.9%) as Allied Health.

******************


ABOUT OUR AGENCY

6. Our agency type is:

Figure 1-54

Specialist

Psychosocial Day Program / Specialist community falls prevention service / Specialist service for victims /

and their support persons, in relation to sexual assault and family violence.

Other

Brokerage Services following post public hospital discharge / Case management and services delivered into

the client's home / Community agency / Community Nursing, Community rehabilitation i.e. ambulatory

multidisciplinary care / Complex Care, Complex Case Management with brokerage service (2 funding

sources; Linkages and Aged Care Packages) / Division of General Practice / Funded by a range of federal

and State Government Departments to support carers of people who have a disability mental illness or are

frail due to age / Generalist / HACC Linkages Case Management / Aged Care Packages / HARP program /

in-reach residential care / Non Government Organisation (Psychiatric Disability Rehabilitation Support

Service (PDRSS)) / Not For Profit Community Service Provider (CACP Packages) / Outreach Service

(Community Health) / Single point of entry for Peninsula Health sub-acute services / Supports unpaid

carers in the community; Aged, Disability, Mental Health, Young carers / We provided respite to families of

children with a disability which covers mental health under the HACC program.

From the overall respondent number of 87, 83 answered this question with 30 respondents (36.1%) indicating that

they were from a Community Health agency. A significant number (26 or 31.3%) identified Other and specified the

diversity of different agencies listed.

7. Our agency catchment is:

The diversity of clients and providers surveyed through the Client journey project makes it

difficult to correlate precisely the catchment boundaries for all Service Providers.

A number of smaller agencies serve clients with specific needs rather than from defined

boundaries. Other agencies have large catchment areas that cut across Local Government and

DHS DoH boundaries whilst the larger DHS / DoH funded agencies tend to identify within the

DHS / DoH Southern Region boundaries.

However, all agencies identified Frankston and Mornington Peninsula (all or part) as being (or

being within) their catchment boundaries.


8. Our agency/program/department works predominantly with a particular client group.

Figure 1-55

Of the 66 (out of 87) respondents who answered this question, 53 (80.3%) indicated that their agency worked

predominantly with a particular client group.

9. Identified Client Groups.

The responses reflect a broad diversity of client groups serviced by the provider. They

cover sectors such as aged, mental health, disability, chronic disease services, aged care,

children’s services, socially isolated, residential care, etc. A full list of responses can be

seen in Appendix Two.

10. Our agency primarily services the age demographic/life stages of:

Figure 1-56

Of the 87 overall respondents, 66 answered this question. The greatest number (n=35 or 53%) indicated that they

primarily provided services to older persons.

******************


ABOUT OUR CLIENTS 11. The Percentage of our client base which is in the 50-80+ group is:

Figure 1-57

Out of the 58 who responded to this question, 14 (24.1%) identified that between 71-80% of their client base was in

the 50-80+ age grouping. This matches well with one focus of the survey being on the older aged client.

12. The percentage of our older client base who would have a diagnosis of dementia:

Figure 1-58

Out of the 57 who responded to this question, 20 (35.1%) identified that between 0-10% of their older client base

had a diagnosis of dementia.


13. The percentage of our older client base who would have a diagnosis of depression:

Figure1-59

Of the 56 who responded to this question, 13 (23.2%) were unsure as to whether their older client base had a

diagnosis of depression, the second highest response, 8 (14.3%) indicated that they thought that between 31-40% of

their older clients might have depression as a diagnosis.

14. The percentage of our older client base who would have a diagnosis of anxiety:

Figure 1-60

Of the 56 who responded to this question, 16 (28.6%) were unsure as to whether their older client base had a

diagnosis of anxiety, the second highest response, 15 (26.8%) indicated that they thought that between 11-20% of

their older clients might have anxiety as a diagnosis.


15. We would rate (out of 100) the process for identifying clients with a diagnosis of

dementia as (low 0-20 / moderate 30-60 / high 70-100):

Figure 1-61

When responding as to how they would rate their processes (on a scale of 0-100) for identifying clients with a

diagnosis of dementia, of the 53 respondents who answered this question the 2 most representative answers were 0

(9 responses (17%)) and 10 (9 responses (17.0%)). The absence of an Unsure (electronic questionnaire error) may

have skewed the data somewhat.

Although there is some degree of awareness related to flagging depression and anxiety,

comparatively the process for flagging dementia did not rate as high. This is reflected in the

response to question 12 (% of clients who have a diagnosis of dementia) 35.1% identified that

between 0-10% of their older client base had a diagnosis of dementia and take into account

and given the process for identifying clients with depression and anxiety (questions16 & 17) ,

it is reasonable to assume that ensuring that there are adequate processes for recognition of

clients with these conditions (dementia, depression and anxiety) is of high importance to

improve client care coordination to ensure they are receiving the most appropriate care.

16.We would rate (out of 100) the process for identifying clients with a diagnosis of

depression as (low 0-20 / moderate 30-60 / high 70-100):

Figure 1-62


diagnosis of depression, of the 59 respondents who answered this question, 10 respondents (16.9%) scored at 80, the

second highest being 8 respondents (13.6%) who scored at 10.


17. We would rate (out of 100) the process for identifying clients with a diagnosis of

anxiety as (low 0-20 / moderate 30-60 / high 70-100):

Figure 1-63


diagnosis of anxiety, of the 59 respondents who answered this question, 9 respondents (15.3%) scored as unsure, the

second highest being 7 respondents (11.9%) shared between 3 scores (10, 30 and 80).

SUMMARY � Currently there is a gap in screening and identification of clients with dementia, depression

and anxiety. The use of appropriate tools for these processes for recognition of client with

these conditions (dementia, depression and anxiety) is important to enable appropriate

screening, assessment and referral processes to enhance coordination of their care. Clients

needs beyond the presenting issue do not appear to be systematically or consistently

flagged for their broader needs. Service providers are not always aware of whether or

not there are internal processes available to them for identification of clients with

dementia, depression or anxiety.

******************

ABOUT OUR STRUCTURES & PROCESSES Regarding the following two questions a distinction is made between access to information

(question 18) and access to the service (question 19). Several comments made in

response to both questions 18 & 19 are closely linked in their responses.


18.Our access and intake structures facilitate streamlined and integrated access to

information for our clients.

Figure 1-64

Of the 61 respondents who answered this question, 50 (82%) indicated that their access and intake structures did

facilitate streamlined and integrated access to information for their clients. A range of comments was provided with

this question, a representational sample can be seen in Appendix Two.

The service provider comments associated with this question regarding the intake structures

facilitating access to information, and the following question about integrated access to

services, demonstrated a wide variety of structures from centralised access systems to

multiple entry systems which could be confusing for clients to navigate. However, this is a

recognised issue for some service providers which they are addressing, for example:

“Too confusing at present with multiple entry methods and not good

protocols across the various units (current project underway to

address.”

There is also evidence of various staffing models, some of which appear to be more effective

operationally than others, having a reduced capacity for staff to manage the stresses of heavy

workloads which may point to a need for more streamlined systems to be put into place.

“Time does not permit the staff to provide a streamlined integrated

access to information, they do their best but we are understaffed and it

is a very stressful busy role. Frequently elderly people are a challenge

to keep on track (as to why they are calling) on the phone.”


19. Our access and intake structures facilitate streamlined and integrated access to

services for our clients.

Figure 1-65

Of the 61 respondents who answered this question, 48 (78.7%) indicated that their access and intake structures did

facilitate streamlined and integrated access to services for their clients. A range of comments was provided with this

question, a representational sample can be seen in Appendix Two.

Whilst almost 79% indicated streamlined and integrated structures it would appear from the

representative comments (Appendix 2) there are more than 20% of respondent services which

do not have fully integrated and streamlined intake structures. There is more work to be done

in integrating and streamlining access to services for clients. There is a need for streamlined

access practices to be integrated into policy, work plans and position descriptions where

applicable.

“An area of improvement in progress with the development of a single

point of access.”

82% & 78.9% respectively of the respondents to questions 18 & 19 indicated that their

access and intake structures did facilitate streamlined and integrated access to

information and services for their clients. However, in the 2009 Department of Health

Service Coordination/ICDM Survey Part A 65% of the program respondents from the

Frankston Mornington Peninsula Catchment identified that service coordination practice

standards and program requirements are only partially integrated into policy, work plans

and position descriptions where applicable. That response is at variance to those in this

study indicating a potential disparity in what is understood about current practice.

Overall it is clear that continued streamlining of current intake structures and staffing models

is desirable to:

• improve access to services for clients

• to ensure that clients are receiving the attention and time appropriate to meet their

needs

• take into account the limitations of staffing models which have to accommodate the

pressures of heavy workloads


20. We would rate our organisation’s client focused care (out of 100) as being (lowest

0-20 / moderate 30-60 / highest 70-100):

Client-Centred Care is health care that establishes a partnership among practitioners,

patients, and their families (where appropriate) to ensure that decisions respect patients’

wants, needs, and preferences and that patients have the education and support they

need to make decisions and participate in their own care32

Figure 1-66

When responding as to how they would rate their client focused care (on a scale of 0-100), of the 61 respondents who

answered this question, 20 respondents (32.8%) scored at 90, the second highest being 10 respondents (16.4%) at

80.

Although 73% of Agencies identified their organisation’s Client Focused Care as being in

the highest rating category this is not fully supported in other document sources such as

the regional Department of Health Service Coordination/ICDM B 2009 survey care in which

45% of those agencies who completed the survey stated that less than 10% of people

received a care plan in which their consumer stated or agreed issues/problems;

objectives/goals were addressed. This would indicate the need for service providers to be

developing a clear understanding of what Client Focused Care means and how

organisations can measure this.

SUMMARY � There is a wide variety of structures from centralised access systems to multiple entry

systems which is confusing for clients to navigate. More work is required to further

integrate and streamline access to services for clients. Functional access structures are

essential. Such access models would integrate policies, work plans and position

descriptions so that there is clear delineation of roles and responsibilities where

applicable.

� Although there is an emphasis of Client Focussed Care reflected in the service provider

responses the disparity between different survey responses supposes the need for developing

32 Institute of Medicine (2001), Envisioning the national health care quality report. Washington, DC: National

Academy Press. http://www.nap.edu/catalog.php?record_id=10073#


a clear understanding of what Client Focused Care means. More work could to be done on

developing qualifiers to measure this approach.

******************

SERVICE ACCESSIBILITY

21. Upon presentation to our agency the health and well being of our clients is monitored according to their level of risk:

Clearly documented processes, practices and protocols assist in clarification of approach

and are an essential component of a sound clinical governance framework and

coordination of care. Well developed evidenced based guidelines also inform clinical

decision making and guide practice amongst clinicians.

Figure 1-67

Of the 56 respondents who answered this question, 40 (71.4%) indicated that they Always and 13 (23.2%) Usually

monitored their clients health and well being according to their level of risk.

Documentation that supports services to identify the best place to treat clients based on

their clinical risk will enhance effective service coordination practice, quality of care and

better health care experiences for the client. For example if a referrer is aware of an

organisations eligibility and core service focus they maybe able to provide more precise

referral information to assist in coordination of client care based on client need.33

22. The time frame within which our clients are seen by a practitioner from the time

they first contact the service is:

Service providers were asked to answer either this question or question 23 – whichever

was the most relevant to their situation. They were not expected to answer both.

Nevertheless, there was some confusion with answering questions 22 & 23, whilst the 2

33 Care in your Community, Diabetes Service Mapping - Final Report 2009, Peninsula Health


questions were labelled “If you have answered QX do not answer QX” there was an issue

with the question numbers allocated within the electronic tool. However most respondents

identified the issue in their comments and adjusted accordingly.

Figure 1-68

Of the 53 respondents who answered this question, 29 (54.7%) indicated an answer different to those on offer. Of the

section offered, the most commonly chosen answer was 1 month (10 respondents (18.9%). A range of comments was

provided with this question, a representational sample can be seen in Appendix Two.

Whilst nearly all agencies indicated that clients / patients are seen according to need there

exists a wide range of timeframes for practitioners seeing client from when they first accessed

services. However, although this might be expected given the diversity of service providers

(and services), it raises questions about service provider communication to referrers regarding

outcomes of referrals given such a variation of timeframes exists. The diversity of variation in

timeframes and practice is reflected in the comments below and further representational

comments in Appendix 2.

� “Intake response is same day 1st face to face contact if required will

be within 2 weeks unless it is deemed that a more urgent response

is required.”

� “Due to increasing demand for service our waiting period is

currently 4 to 5 weeks. However all clients are triaged according to

risk and urgent clients will be seen within 1 week.”

� “Varies across the sites and across disciplines”

� “Varies from same day to 3 months according to which service the

client requires varies depending on the service requested and

current wait times.”

� “People with highest need have priority but contact times depend on

effective communication between prospective clients, referrers and

staff.”

The variability highlights the dynamic nature of our service system and the importance of

ongoing communication between services to coordinate client care.


23. The time frame within which our clients are seen by a practitioner from the time


Figure 1-69

Of the 34 respondents who answered this question, 9 (26.5%) answered Urgent, 4 (11.8%) Non Urgent, 4 (11.8%)

Other and 17 (50% provided clarifying comments or additional information).

Whilst nearly all agencies indicated that clients / patients are seen according to need there

exists a wide range of timeframes.

24. Our appointment scheduling timeframes are:

Once again, whilst nearly all agencies indicated that clients / patients are seen according to

need there exists a wide range of timeframes definition and application. The broad range of

comments illustrating disparate understandings was provided with this question raising issues

about the knowledge of prioritisation systems within the service by individual service

providers.

� “People with highest need have priority but contact times depend

on effective communication between prospective clients, referrers and

staff.”

� “No idea how access work the priority system or even if there is

one.”

A further representational sample of comments is contained in Appendix Two.


Urgent

Figure 1-70

Of the 56 respondents 39.3% indicated timeframes for Urgent are 24hrs, 25% 1-2 days. 17.9% of Urgent were made within timeframes ‘Other’ than those indicated.

• if palliative care required maybe 24 hrs.

• Urgent - 3 business days.

Routine

Figure 1-71

Of the 56 respondents 35.7% indicated their Routine appointments were made within timeframes ‘Other’ than

those indicated, 23.2% were in 7 days.

• Routine (and Low) 7 days for phone contact, assessment within 14.

• Routine - 10 business days.


Low

Figure 1-72

Of the 56 respondents 41.1% indicated their Low appointments were made within timeframes ‘Other’ than

those indicated, 25% were in 14 days, 16.1% were within 1 month

Again, whilst nearly all agencies indicated that clients / patients are seen according to

need there exists a wide range of timeframes definition and application. Of the 56

respondents who answered this question, 40 (71.4%) indicated that they Always and 13

(23.2%), Usually monitored their clients’ health and well being according to their level of

risk. Almost 40% indicated that they considered an Urgent timeframe as being within

24hrs and a further 25% within 1-2days of contact. There is significant variability for

Routine and Low timeframe.

It is worth noting that the highest response in the last 3 graphs is ‘Other’ and upon further

examination of the comments such as:

� “No idea how access work the priority system or even if there is one.”

� “People with highest need have priority but contact times depend on effective communication between prospective clients, referrers and

staff.”

A diversity of process, practice and application has been identified. This is at odds with

the current service coordination practice standards reflected in the Victorian Service

Coordination Practice Manual (VSCPM).34 It is essential to client focused care that there

are agreed indicators to flag ‘at risk’ clients upon presentation to a service to ensure

continuity of care across services and the client care continuum.

34 Primary Care Partnerships, Victoria, Victorian Service Coordination Practice Manual 2009 practice standards are as follows:

� “The service provider conducts an Initial Needs Identification within no more than 7 working days of Initial Contact or of receiving a referral identified as low or routine from Initial Contact.

� The service provider conducts an Initial Needs Identification within no more than 2 working days of Initial Contact or of receiving a referral identified as urgent from Initial Contact.

� The service provider has in place a process for consumers who require urgent services and cannot wait for a formal assessment process to be completed.”


25. Our clients would know that they are eligible to receive services from our agency

within what timeframe?

Figure 1-73

Of the 56 respondents who answered this question, 20 (35.7%) indicated that their clients would know that they are

eligible to receive services within 1 day. Of note, percentages add to greater than 100% as a number of agencies

provided a response to Other in addition to designating a timeframe. A range of comments was provided with this

question, a representational sample can be seen in Appendix Two.

This response is consistent with the clients response in the consumer section Question 8 where

Of the 57 consumer responses 32% (n=18) indicated that they had received help on the Same

day they contacted the service, 26% (n=15) received assistance within 2-3 days.

Consolidating, 58% received help within 2-3 days at the most of requesting it.

26. We ensure that the client has the information they need to understand what is

happening to them throughout their whole care experience.

Figure 1-74

Of the 56 respondents who answered this question, 40 (71.4%) indicated that they Always, or 14 (25%) Usually

ensured that their clients had the information to ensure that they knew what was happening to them during their

whole care experience.

SUMMARY � There is a clear perception that monitoring of client risk at presentation is

supported by consistent practice across service providers regarding effective


communication of timeframes, eligibility and prioritisation across services in

accordance with good practice and may improve client care coordination. It is

essential to client focused care that there are agreed indicators to flag ‘at risk’

clients upon presentation to a service to ensure continuity of care across services

and the client care continuum.

� Whilst nearly all agencies indicated that clients are seen according to need there

exists a wide range of timeframes for practitioners seeing clients from when clients

first access services. This raises questions about service provider communication to

referrers regarding outcomes of referrals given such a variation of timeframes exists.

The variability highlights the dynamic nature of our service system and the

importance of ongoing communication between services to coordinate client care.

******************

ASSESSMENT & CARE COORDINATION

27. Care coordination should be an equal partnership between clients and service providers.

Figure 1-75

53 respondents answered this question and indicated that they Strongly agree (37 respondents or 69.8%) or Agree

(12 respondents or 22.6%) that care coordination should be an equal partnership between clients and service

providers.

28. Our assessment process identifies client needs beyond the presenting issue.

Figure 1-76


Of the 53 respondents who answered this question, indicated that they Always (26 or 49.1%), or Usually (22 or

41.5%) ensured that their assessment process identified client needs beyond the presenting issue.

In comparison to the above findings the Department of Health Service Coordination/ICDM

2009 survey results for Frankston/Mornington Peninsula identified the following:

• 36% of agencies surveyed identified less than 10% of consumers had an assessment that

identified their broader needs

• 55% of agencies identified that between 50 and 90% of consumers had their broader

needs identified

• 9% of the agencies identified that more that more than 90% of consumers had their

broader needs identified.

It is again recognised through this study that variability exists in what the consumer can

expect from a service in terms of a holistic assessment process.

29. Our assessment process identifies client capability for self management and

behaviour change.

Self-management is the ability of the client to deal with all that a chronic disease entails,

including symptoms, treatment, physical and social consequences, and lifestyle changes. Self-

management interventions aim to place the person in control of their life and assist them to be

as independent as possible, rather than creating health system dependency.35

Figure 1-77

In response to the assessment process identifying capacity for self-management and behaviour change, of the 53

respondents who answered this question, 18 (34%) indicated that the Always or 25 (47.2%), Usually did.

The resultant 47% of service providers “Usually” identifying client capability for self

management in the assessment process highlights an inconsistency in practice. From this

result it appears that service providers may view as optional whether or not a service

provider has a choice about implementing good practice around self management delivery.

Consistent and standardised self management practice such as that outlined in the Active

Service Model (ASM-HACC) Guidelines36, calls for processes and tools to be employed

which enable clients self management support at organisational and practitioner levels to

ensure client self management capacity is clearly and accurately identified.

35 Primary Care Partnerships, Victorian Service Coordination Practice Manual, 2007


2010 and Commonwealth of Australia 2007, Australian Government Department of Health and Aging, National HACC Program Guidelines for the Home and Community Care Program, 2007


30. We develop care plans or use a care planning template.

Figure 1-78

Of the 53 respondents to the development of Care Plans or use of a care planning template, 33 (62.3%) indicated that

they Always or 9 (17.0%) Usually used one.

Respondents were not asked to provide information regarding what care planning

templates they used. It is therefore assumed that a variety of care planning templates is

actually in use. One of the key features of care planning indicated in the Victorian Service

Coordination Practice Manual (VSCPM) is the use of the SCTT Care Coordination Plan

template for intra and inter-agency care planning.37 It is also one of the Good Practice

Indicators.

31. When developing care plans we take into account Health Promotion and

prevention.

The identification of health promotion/prevention opportunities, early intervention, self

management capabilities are vital in the development of client care plans. In accordance

with the Victorian Service Coordination Practice Manual, client centred practice supports

clients to examine potential risks and consequences38 of current health related behaviour.

Figure 1-79

37 Primary Care Partnerships, Victoria, Victorian Service Coordination Practice Manual 2009 – pgs 26, 28-29, 33, 34 - Section

4.8 “How to Develop a Care Coordination Plan”

38 Primary Care Partnerships, Victoria, Victorian Service Coordination Practice Manual 2009 – pgs 27


Of 53 respondents, 19 (35.8%) and 21 (39.6%) indicated respectively, that they Always or Usually took Heath

Promotion & prevention into account when developing care plans.

32. When developing care plans we take into account early intervention.

Figure 1-80

Of 53 respondents, 31 (58.5%) and 11 (20.8%) indicated respectively, that they Always or Usually took early

intervention into account when developing care plans.

33. When developing care plans we take into account self management capabilities.

Figure 1-81

Of 53 respondents, 32 (60.4%) and 13 (24.5%) indicated respectively, that they Always or Usually took early

intervention into account when developing care plans.

34. Does the client record include the date a care/treatment plan was developed?

Questions 34 – 42 relate to the development of the care plan. These questions reflect the

elements which should be included in the client’s care plan in accordance with the Good

Practice Indicators in the Victorian Service Coordination Practice Manual (VSCPM).39

39 Primary Care Partnerships, Victoria, Victorian Service Coordination Practice Manual 2009 – pg 27, Section 4.4, “What is a

Care Plan?”


Figure 1-82

Of 53 respondents, when responding to inclusions on the client record, 36 (67.9%) and 12 (22.6%) indicated

respectively that the client record Always or Usually include the date the care/treatment plan was developed.

35. Does the client record include the participants in the development of the care

plan?

Figure 1-83


respectively that the client record Always or Usually includes the date the care/treatment plan was developed.


36. Does the client record include client stated and agreed issues or problems?

Figure 1-84

Of 53 respondents, when responding to inclusions on the client record, 29 (54.7%) and 18 (34%) indicated

respectively that the client record Always or Usually includes client stated and agreed issues or problems.

37. Does the client record include client stated and agreed goals?

Figure 1-85


respectively that the client record Always or Usually includes client stated and agreed goals.


38. Does the client record include agreed actions and the name of the person or

service responsible for each action?

Figure 1-86

Of 53 respondents, when responding to inclusions on the client record, 25 (47.2%) and 18 (34%) indicated

respectively that the client record Always or Usually includes agreed actions and then name of the person or service

responsible for each action.

39. Does the client record include timeframe for attaining goals and actions?

Figure 1-87

Of 53 respondents, when responding to inclusion on the client record, 14 (26.4%) and 19 (35.8%) indicated

respectively that the client record Always or Usually includes the timeframe for attaining goals and actions.


40. Does the client record include planning review date?

Figure 1-88


respectively that the client record Always or Usually includes a planning review date.

41.Does the client record include client acknowledgement of the care plan (signed or

verbal)?

Figure 1-89

Of 53 respondents, when responding to inclusions the client record, 35 (66%) and 11 (20.8%) indicated respectively

that the client record Always or Usually includes a client acknowledgement of the care plan.


42. Does the client record include the actual review date?

Figure 1-90

Of 53 respondents, when responding to inclusions the client record, 23 (43.4%) and 13 (24.5%) indicated respectively

that the client record Always or Usually includes the actual review date.

43. Are your clients actively involved in developing their treatment/care plans?

Figure 1-91

Of 53 respondents, 34 (64.2%) indicated that their clients were actively Very involved all of the time or Involved

some of the time (15 or 28.3%) in developing their treatment/care plans.

In regard to Questions 30 – 43 about care planning there appears inconsistency between what

service providers report in relationship to care planning and what the findings have

demonstrated in the consumer component of this report.

For example, clients stating that they do not have a copy of their care plan which is an

essential component of the care planning practice casts some doubt over the above responses.

The Victorian Service Coordination Good Practice Guide for Practitioners states that a “care

plan is used to empower the consumer to participate in the development, implementation,

monitoring and review of their service coordination plan”. However, whilst 63% of clients

identified that they had a care plan 58% responded that they did not have a written copy. The

client response is also consistent with the Department of Service Coordination/ICDM B 2009


Survey results where 45% of agencies surveyed identified that less than 10% of clients had a

care plan.

A potential task for services to validate their actual practice may be to conduct a file audit of

current practice utilising VHA Care Planning Indicators for Community Health.40

44. Does the agency assessment process include clients stated issues and

aspirations?

Figure 1-92

Of 53 respondents, 26 (49.1%) indicated that their assessment process Always or Usually (16 or 30.2%) includes

client stated issues and aspirations.

45.We ask clients what their goals are for their care.

Figure 1-93

Of 53 respondents, 35 (66%) indicated that they Always or Usually (14 or 26.4%) ask clients what their goals for

care are.

40 Victorian Healthcare Association (2008), Clinical Indicators in Community Health. Melbourne, Australia. http://www.vha.org.au/uploads/VHA%20Indicator%20Final%20June%2009.pdf


46.We ask carer/s what their goals are for the care of the client.

Figure 1-94

Of 53 respondents, 26 (49.1%) indicated that they Always or Usually (17 or 32.1%) ask carers what their goals are

for the care of their client.

Carer involvement in the development of client care plans is essential. While 49.1% service

providers do engage the carer in the development of client care plans, given that 32.1% of

service providers Usually involve carers in the care planning process is an indicator that there

is some inconsistency of practice which has broad implications for the continuity of care for

clients.

In the client survey many clients noted that services did not involve carers enough, even

though carers took full time responsibility for meeting the needs of the client outside the

service.

47. Our clients are given information to enable them to make an informed choice

about discharge or transfer from our service/agency.

Figure 1-95

Of 53 respondents to this question, 31 (58.5%) indicated that they Always or Usually (16 or 30.2%) give information

to clients to enable them to make informed choices about discharge or transfer from their agency.

The Consumer Outcomes and Good Practice Indicators in the Victorian Service Coordination

Practice Manual 2009 states that “the service provider presents information that empowers the


consumer to make informed choices”. 58.5% of respondents indicated this is their normal

practice. However there are still 35.9% of service providers who do not necessarily undertake

this practice consistently leaving clients potentially without the necessary information that

helps them to make the informed choices that give clients the confidence that they know what

is happening next as they transfer or discharge out of any given service.

48. We are responsive when clients request information about their health condition

and/or care plan.

Figure 1-96

Again, of 53 respondents, 40 (75.5%) indicated that they Always or Usually (10 or 18.9%) are responsive when

clients request information about their health condition or plan of care.

Consistently noted throughout the client component of this document is the importance clients

place in relation to timeliness of information when they are seeking assistance. Client

engagement is an essential component of self management and helps to build trust and

establish the client and service provider relationship.

49. We are responsive when carers request information about the client’s health

condition and/or care plan (with clients consent).

Figure 1-97

Of 53 respondents, 35 (66%) indicated that they Always or Usually (12 or 22.6%) responsive when carers request

information about their clients health condition or plan of care.


Clear communication to carers is an essential component of coordinating client care, carers

themselves need to feel and be well informed in order to meet the need of the client under

their care. There are clear indications in the responses that this is generally common practice.

50. We normally ask for our client’s consent to allow our services to access and share

their personal details and health information with other service providers.

’ Figure 1-98

51 (96.2%) of 53 respondents, indicated that they normally ask for a client’s consent before sharing information with

other health service providers. A range of comments was provided with this question, a representational sample can

be seen in Appendix Two.

This response is at odds with question 18 of the client survey component in which 52% of

clients stated they had not been asked to give their consent prior to their sharing of

information with other services. Clear lines of communication are essential to the client being

able to understand the role they play in their health own management. This not only infers

that information is given to the client but that they understand the information has been

communicated.

51. We regularly include general practitioners as part of the care planning process

(where relevant).

Figure 1-99

In response to the question as to whether they regularly included general practitioners in the care planning process, of

53 respondents, 18 (34%) indicated Always, 11 (20.8%) Usually, 17 (32.1%) Sometimes.


The above responses highlight the lack of consistency in feedback to general practitioners,

further emphasising this point and its potential to cause disruption to care coordination is that

the client identifies the G.P. as central to their first point of call when unwell however the

general practitioners care is jeopardised if lack of communication and feedback inhibits their

whole picture of the client. This is not in keeping with General Practice Victoria (GPV) &

Department of Health (DH) position.41

52. Our organisation has a system for recall, reminder, monitoring and review of care

plans.

Figure 1-100

Of 53 respondents, 31 (58.5%) indicated that their organisation has a system for recall, reminder, monitoring and

review of care plans. A range of comments was provided with this question, a representational sample can be seen in

Appendix Two.

The Wagner Model42 for chronic care identifies systems for recall and reminder as essential

components of chronic disease management. This also highlights the importance of developing

systems and supports for tracking and recalling clients at both an organisational and practice

level. Effective systems on an organisational level that enable planned care can potentially

41 Extract sourced from: General Practice Victoria (GPV) & Department of Health (DH) – General Practice Engagement in

Integrated Chronic Disease Management – A Resource for Primary Care Partnerships – Fact Sheet -

http://www.health.vic.gov.au/communityhealth/downloads/gp_engagement_icdm.pdf

“Sharing information between agencies and GPs can be enhanced by health care

organisations having systems and policies for:

• Acknowledging and accepting referrals from GPs;

• Informing GPs of treatment plans and treatment outcomes; and

• Requesting clinical results and medical history to assist with treatment plans or

• Measuring effectiveness of interventions.

Requesting involvement in a care planning process includes:

• Involving GPs in the care planning process, particularly where there is complexity;

• Understanding the Medicare Benefits Schedule items which general practice use for care planning, including

establishing and/or reviewing GP-led GP Management Plans;

• (MBS #721) and Team Care Arrangements (#723) plans, or involving GPs in care plans led by other health

practitioners (#729); and

• Understanding the responsibilities inherent in accepting a referral through a Team Care Arrangement.”


Melbourne, Victoria, Revised Chronic Disease Management Program Guidelines for Primary Care Partnerships and Primary Health Care Services, October 2008. Also see Page 16 of this document for a diagram of the Wagner Model.


impact on unplanned Emergency Department admissions as the client has ad hoc contact with

the service based on episodic care rather than periodic monitoring and review. The fact that

42% of service providers are unsure about, or do not know if their organisation has a

monitoring/reminder/recall system is problematic. Such a large percentage of service

providers indicating their uncertainty about the system reinforces the fact that this may

contribute to unplanned Emergency Department admissions and impact client outcomes at

practice level.

53. We contact our clients for follow up/recall appointments/reviews.

Figure 1-101

When asked whether they contacted their clients for follow up/recall of 53 respondents, 16 (30.2%) indicated Always,

18 (34%) Usually and 10 (18.9%) Sometimes. A range of comments was provided with this question, a

representational sample can be seen in Appendix Two.

52.9% of service providers indicating that they either Usually or Sometimes contact their

clients for followup/recall indicates that at practice level even if a system is in place at an

organisational level there is practice variability which may result in clients potentially falling

through the cracks in the system with pre-existing conditions not being appropriately managed

or supported in the longer term. It also raises questions regarding how services measure the

efficacy of treatment which has been prescribed and client outcomes.

54. Our client records indicate that planned reviews have occurred within one month

of the date listed for review.

Figure 1-102


Of 53 respondents 12 (22.6%) answered that their records indicate that planned reviews have Always occurred within

one month of the listed review date, 20 (37.7%) that this Usually occurred and 6 (11.3%) that this occurred

Sometimes. A range of comments was provided with this question, a representational sample can be seen in

Appendix Two.

These findings are consistent with Question 53 in that again there is a lack of consistent

practice to support systematic followup of client.

55. We offer information and support through the provision of self management

opportunities to our clients to help them manage their condition/situation.

Figure 1-103

20 (37.7%) of 53 respondents indicated that they Always offer information and support through the provision of self-

management opportunities with 23 (43.4%) indicating that this Usually occurred. A range of comments was provided

with this question, a representational sample can be seen in Appendix Two.

For additional information response to questions asked about self management also see

questions 29 and 43 in the service provider section.

56. We are satisfied that our clients’ health needs are well coordinated between services within our agency and with our service providers.

Figure 1-104

When asked about their level of satisfaction that their client’s health needs are being well coordinated, of 53

respondents, only 7 (13.2%) indicated that they were Very satisfied, 40 (75.5%) that they were Mostly satisfied

and 4 (7.5%) that they were Mostly dissatisfied.


Although 75.5% service providers indicated they were Mostly satsified about client health

needs being well coordination between service within their agency and with other agencies the

questions needs to be asked – what aspects of care coordination are they dissatisfied with?

The question below attempts to answer what could be done to improve intra and inter agency

care coordination.

57. What could be done to improve coordination between our agency and other

service providers?

Figure 1-105

A number of responses had elements of one, two or three of the identified themes. There were several comments

which included a component concerning improvement of technology across the service system (14%,n=6). However,

Service Providers clearly identified improved system knowledge and coordination (41%,n=18) and improved client

specific referral, communication and coordination (45%,n=20) as being key to improving coordination across the

system.

With respect to improved coordination between service providers, there is remarkable

coherence across the responses from a diversity of organisations. These have been collated

and identified into three distinct categories:

A. Improved technology

B. Improved system wide knowledge and coordination

C. Improved client specific referral, communication and coordination

For a full listing of service provider responses to this question please see Appendix Two.

SUMMARY

� Variability exists in what the consumer can expect from a service in terms of a holistic

assessment process.

� Inconsistent practice in identifying client capability for self management in the

assessment process highlights has been identified through the study. It appears that

service providers may view as optional whether or not a service provider has a choice

about implementing good practice around self management delivery. Consistent and

standardised self management practice calls for processes and tools to be employed

which enable clients self management support at organisational and practitioner levels to

ensure client self management capacity is clearly and accurately identified. The current


inconsistent practice is supported by a lack of use of Consistent and standardised

processes and tools relating to self management.

� Care plans aim to take into account health promotion/prevention/early intervention/self

management capabilities and opportunities. Completing all elements of a care plan such as

client stated issues/needs, etc. are considered essential for care planning development. There

appears to be inconsistency between what service providers report in relationship to care

planning and what the findings have demonstrated in the consumer component of this report.

Despite the majority of service providers indicating consistent care planning practice there is

still demonstrated variable practice among service providers reflected in the high percentages

of Usually responses to questions relating to care planning.



perception of clients who stated (52%) that they had not been asked to give consent prior to

sharing their information to other services.

� There is a lack of consistency in feedback and involvement with G.P.’s in the care planning

process. Given that clients see the GP as central to their first point of call and often as their

‘care coordinator’ this has major implications for appropriate care coordination and

streamlined care between services. This is of particular concern for the management of

clients with complex care needs.

� 42% of service providers are unsure about, or do not know if their organisation has a

monitoring/reminder/recall system is problematic. Such a large percentage of service

providers indicating their uncertainty about the system reinforces the fact that this may

contribute to unplanned Emergency Department admissions and impact client outcomes at

practice level. There is practice variability which may result in clients potentially falling

through the cracks in the system with pre-existing conditions not being appropriately

managed or supported in the longer term. It raises questions regarding how services

measure the efficacy of treatment which has been prescribed and client outcomes. This also

relates to issues pertaining to effective and efficient discharge planning practice.

� Service providers identified many areas to improvement. They fall into the categories of:

• improved technology

• improved system wide knowledge and coordination

• improved client specific referral, communication and coordination

******************

REFERRAL & FEEDBACK

58. There is duplication when referring clients from one part of the service to

another.

Stream lined intra agency communication is essential to the care coordination of clients

receiving more than one service from an organisation. Streamlining communication

‘facilitates communication of agreed strategies and service interventions between


practitioners, articulates shared goals and outcomes, outlines roles and responsibilities43

to avoid duplication of services and of the client retelling their story.

Figure 1-106

When asked about the whether there is duplication when referring clients from one part of the services to another, 3

(6.9%) of 46 respondents indicated that there Always while 9 (19.6%) indicated that this was Usually the case, 15

(32.6%) Sometimes and 15 (32.6%) that duplication Rarely occurred.

Of concern is that 52.2% of services indicated there is some duplication in intra-agency

referral. This level of response clearly identifies that more work needs to be undertaken to

effectively communicate clients needs to each other through effective internal referral

practice being established.

59. There is duplication when referring clients from our agency to other agencies.

Figure 1-107

When asked about the whether there is duplication when referring clients from our agency to other agencies, 6 (13%)

of 46 respondents indicated that there Always was, 11 (23.9%) indicated that this was Usually the case, 13 (28.3%)

Sometimes and 13 (28.3%) that duplication Rarely occurred.

Responses for the above question closely mirror those of the previous question and once

again highlight potential problems for coordinating care for clients and the necessity of

establishing good referral practices through appropriate systems & process to

43 Primary Care Partnerships, Good Practice Guide - A Resource of the Victorian Service Coordination Practice Manual - Pg 11


communicate clients needs to each other. This also highlights the need for effective

implementation and ongoing use of electronic referral systems and appropriate use of

SCTT tools to support inter- agency care coordination for shared clients.

60. We send clients referrals which have been prioritised as urgent within no more

than 1 working day of obtaining client consent.

Figure 1-108

Of the 46 respondents, 18 (39.1%) indicated that they Always send urgent client referrals within 1 working day of

receipt of consent. 21 (45.7%) indicated that this Usually occurred with a much smaller number 2 (4.3%) advising

that this occurred only Sometimes.

45.7% indicated that they Usually sent client referrals prioritised as urgent within no

more than 1 working day. Further exploration regarding why a client prioritised as urgent

would not be referred within that timeframe needs to be explored further as this poses a

clinical risk and could precipitate a hospitalisation or emergency department presentation.

It may be useful to identify whether these are system or resource issues.

61. We send clients referrals which have been prioritised as low or routine within 7

working days of obtaining client consent.

Figure 1-109

Of 46 respondents, 16 (34.8%) indicated that they Always send low or routine client referrals within 7 working day of

receipt of consent. 21 (45.7%) indicated that this Usually occurred with a much smaller number 3 (6.5%) advising

that this occurred only Sometimes.


Variation in responses in relation to timeframes also has implications for care coordination.

It is important that services have an understanding of how they coordinate their referrals

to each other and what can be expected in terms of flow of client information.

62. We transmit Referral Acknowledgement to referring service providers for urgent

referrals within no more than 2 days of receiving the referral.

Figure 1-110

Of 46 respondents, 11 (23.9%) indicated that they Always send a Referral Acknowledgement to referring providers

for urgent referral no more than 2 working days of receipt of referral. 7 (15.2%) indicated that this Usually occurred,

3 (6.5%) advising that this occurred only Sometimes, 9 (19.6%) that this Rarely and 5 (10.9%) that this Never

occurs. 10 (21.7%) of respondents indicated that they Don’t know whether this occurred or not.

When receiving a referral it is good practice to acknowledge receipt of the referral or to

return inappropriate referrals to the sending agency with an explanation.

63. We transmit to referring service providers a Referral Acknowledgement for low or

routine referrals within no more than 7 days of receiving the referral.

Figure 1-111

Of 46 respondents, 11 (23.9%) indicated that they Always send a Referral Acknowledgement for low or routine

referrals within no more than 7 working days of receipt of referral. 6 (13%) indicated that this Usually occurred, 7

(15.2%) advising that this occurred only Sometimes, 9 (19.6%) that this Rarely and 3 (6.5%) that this Never

occurs. 10 (21.7%) of respondents indicated that they Don’t know whether this occurred or not.


Again, 10 (21.7%) of respondents indicated that they don’t know whether referral

acknowledgement for low or routine referrals occur or not. The variation in response

clearly demonstrates that there is not a locally agreed standard practice for referral

acknowledgment and overall this has implications regarding communication between

services in relation to client care and outcomes of referrals.

64. We send feedback to the initiating service within 14 working days of the client

being assessed.

Figure 1-112

of 46 respondents, 5 (10.9%) indicated that they Always send feedback to the initiating service within 14 days of the

client being assessed. 11 (23.9%) advised that this occurred only Sometimes, 11 (23.9%) that this Rarely and 1

(2.2%) that this Never occurs. As with preceding questions 62 & 63 the number of respondents indicating that they

Don’t know whether this occurred or not was reasonably significant at 9 (19.6%).

It appears that there is not a clear feedback mechanism agreed upon by services. This

creates a large gap in terms of care coordination and also reinforces the care of the client

in silos rather than a multi disciplinary care team. The Good Practice Guide (for

Practitioners)44 clearly states the following that the consumer can expect:

“the transmission of information about the referral outcome (to agency which initiated the

referral)within no more than 14 days of the consumer being assessed. Referral outcome

information may include relevant assessment findings, services or interventions which will

provided”.

The above results clearly demonstrate that the Guidelines suggested are not currently

being met by many service providers.

44 Primary Care Partnerships, Good Practice Guide - A Resource of the Victorian Service Coordination Practice Manual, pg 16


65. We have a process for communicating with GP’s.

As in Question 51 relating to inclusion of GPs as part of the care planning process, one

part of collaborative care is the communication between service providers and GPs.45

Figure 1-113

68% (31) of 46 respondents indicated that their agency had a process for communicating with client’s General

Practitioners. A range of comments was provided with this question, a representational sample can be seen in

Appendix Two.

Despite the finding of 68% of service providers indicating formalised communication processes

there is still a need for improvement in service provider communication to GP as evidenced by

the following comments:

� “No set process, it is up to the individual clinician to find

acceptable ways to communicate with GPs.”

� “No formal process. HACC services are not regarded by GP’s as a

health service so we are less likely to be involved...however we

see clients regularly in their own homes and can perform a

valuable monitoring function which GP's probably are not aware

of.”

An agreed process means that both parties engaged in the clients care have and expected

standard of performance. Although the majority of agencies identified that they have a

process in place in the next question 50% identified that they only sometimes/rarely

communicated with the G.P.

66. We communicate with the clients’ GP’s.

45 GPV Position Statement, Feedback to GPs about Patient Care, March 2010


Figure 1-114

Of 46 respondents who indicated that their agencies had a process for communicating with GP’s, 22 (47.8%) indicated

that this occurred Routinely, 15 (32.6%) indicated that this Sometimes occurred, 8 (17.4%) advised that this

occurred Rarely.

Again, as in Questions 51 & 65 GPs require written communication from service providers

as, according to the GPV, it:

• enables relevant effective primary health support to be provided

• reduces confusion for the patient/client

• facilitates follow through of management

• is essential to avoid treatment mishap, particularly in regard to medication

• reduces the chance of duplication of management plans and tests, and so saves time

• and money

• increases the chances that the patient follows up on necessary steps

• facilitates continuity of care so that patients/clients’ care is not fragmented

• also increases GPs’ understanding of the role of other service providers and their

contribution to patient/client care. This increases the likelihood of future appropriate

referrals and further cooperation.46

SUMMARY � There are large practice variations between referral timeframes and transmission of

referral acknowledgements. This reinforces the need for the development of local

agreements for referral and the need for clear feedback mechanisms agreed upon by

services.

� Formalised communication processes for service provider/GP communication needs to be

improved. An agreed process means that both parties engaged in the clients care have

and expected standard of performance.

******************

46 GPV Position Statement, Feedback to GPs about Patient Care, March 2010


CLIENT PATHWAY INFORMATION

67. Please provide a brief description or simple diagram of the general client pathway

and through your organisation.

These pathways have been submitted by service providers and provide an indication of the

diversity of systems and practices relating to client access to services and the care

coordination processes supporting the client with the health care system. The pathway

diagrams may be viewed in Appendix 3.


TABLES OF FIGURES Figure Page

Figure 1-1 Service Coordination Context 17

Figure 1-2 Chronic Disease Management Context 17

Figure 1-3 Wagner Model Framework 18

Figure 1-4 Participants 33

Figure 1-5 Who Completed Questionnaire 33

Figure 1-6 Age Group 35

Figure 1-7 Gender 35

Figure 1-8 Country of Birth 36

Figure 1-9 Aboriginal or Torres Strait Islander Origin 36

Figure 1-10 Main Language at Home 36

Figure 1-11 Entitlement Cards 37

Figure 1-12 Marital Status 37

Figure 1-13 Living Arrangements 37

Figure 1-14 Employment Status 38

Figure 1-15 Postcode 38

Figure 1-16 Healthy Lifestyle Encouragement 39

Figure 1-17 Profession – Healthy Lifestyle Encouragement 39

Figure 1-18 Referred to health professional/community svce 40

Figure 1-19 Svce/health professional accessed 40

Figure 1-20 Information Provision 41

Figure 1-21 Need for Interpreter 41

Figure 1-22 Where do you go – Health Services (Priority) 42

Figure 1-23 Where do you go – Health Services (Second Priority) 43

Figure 1-24 Where do you go – Health Services (Third Priority) 43

Figure 1-25 Where do you go – Health Services (Fourth Priority) 44

Figure 1-26 Where do you go – Health Services (Fifth Priority) 44

Figure 1-27 Ease of Access 45

Figure 1-28 Attendance – Health Service 45

Figure 1-29 Which Health Service 45

Figure 1-30 Timeframes – Access 46

Figure 1-31 Information – First Use 47

Figure 1-32 Clear and Accurate Information 47

Figure 1-33 Helpful information 47

Figure 1-34 Encouragement– Healthy Lifestyle 49

Figure 1-35 Treatment / Care Plan 49

Figure 1-36 Written copy of Care Plan 50

Figure 1-37 Multiple Care Plans 50

Figure 1-38 Involvement in Care Plan Development 51

Figure 1-39 Multiple Health Needs 51

Figure 1-40 Referrals 52

Figure 1-41 Care Coordinator 52

Figure 1-42 Who Coordinates Care 52

Figure 1-43 Clear Roles – Coordinating Care 53

Figure 1-44 Consent – Information Sharing 53

Figure 1-45 Contacts for Review 54

Figure 1-46 Information and Support 55

Figure 1-47 Satisfaction Levels 55

Figure 1-48 Experience of Health Services 57

Figure 1-49 First Contact Expectations 61

Figure 1-50 General Expectations 62

Figure 1-51 Organisation Name 68

Figure 1-52 Multiple Responses 69

Figure 1-53 Role in Organisation 70

Figure 1-54 Agency Type 71

Figure 1-55 Client Group 72

Figure 1-56 Client Life Stage 72

Figure 1-57 Client Age 50-80 Years 73


Figure Page

Figure 1-58 Diagnosis of Dementia 73

Figure 1-59 Diagnosis of Depression 74

Figure 1-60 Diagnosis of Anxiety 74

Figure 1-61 Rating for Diagnosis of Dementia 75

Figure 1-62 Rating for Diagnosis of Depression 75

Figure 1-63 Rating for Diagnosis of Anxiety 76

Figure 1-64 Integrated Access to Information 77

Figure 1-65 Integrated Access to Service 78

Figure 1-66 Client Focus – Rating 79

Figure 1-67 Monitoring Client Health – Risk 80

Figure 1-68 Timeframe – First Contact 81

Figure 1-69 Practitioner Timeframe 82

Figure 1-70 Urgent 83

Figure 1-71 Routine 83

Figure 1-72 Low 84

Figure 1-73 Client Knowledge – Timeframes 85

Figure 1-74 Information Provided 85

Figure 1-75 Equal Partnership 86

Figure 1-76 Identifying Client Needs 86

Figure 1-77Client Self Management 87

Figure 1-78 Care Planning Templates 88

Figure 1-79 Health promotion and Prevention 88

Figure 1-80 Early Intervention 89

Figure 1-81 Self Management 89

Figure 1-82 Date – Care / Treatment Plan 90

Figure 1-83 Including Clients in Care Plan Development 90

Figure 1-84 Client Stated Issues / Problems 91

Figure 1-85 Client Stated Goals 91

Figure 1-86 Agreed Actions –Responsibility 92

Figure 1-87 Timeframe for Goals 92

Figure 1-88 Planning Review Date 93

Figure 1-89 Client Acknowledgment 93

Figure 1-90 Actual Review Date 94

Figure 1-91 Client Involvement 94

Figure 1-92 Client Stated Issues / Aspirations 95

Figure 1-93 Client Goals for Care 95

Figure 1-94 Client Goals (carer) 96

Figure 1-95 Information – Discharge / Transfer 96

Figure 1-96 Client Requests 97

Figure 1-97 Information Requests (carer) 97

Figure 1-98 Client Consent 98

Figure 1-99 General Practitioners Included 98

Figure 1-100 Client Recall 99

Figure 1-101 Contact for Recall 100

Figure 1-102 Client Records – Planned Reviews 100

Figure 1-103 Self Management Opportunities – Support 101

Figure 1-104 Well Coordinated Client Health Needs 101

Figure 1-105 Improved coordination 102

Figure 1-106 Duplication – internal 104

Figure 1-107 Duplication – external 104

Figure 1-108 Sending Urgent Client Referrals 105

Figure 1-109 Sending Routine and Low Client Referrals 105

Figure 1-110 Referral Acknowledgements (urgent) 106

Figure 1-111 Referral Acknowledgements (low / routine) 106

Figure 1-112 Feedback 107

Figure 1-113 Communication Process – GP’s 108

Figure 1-114 Communication – GP’s 109

Figure 1-115 Client Pathways 136


BIBLIOGRAPHY Halloran, H, Wood, C, Close, J, Blacker, V, 2009, Improving the Journey, Eastern

Metropolitan Region Type 2 Diabetes System Improvement Project, A joint initiative of the

Inner East Primary Care Partnership and the Outer East Health and Community Support

Alliance, 2007-2009

Hawke, K, Wright, L, How Projects, South East Healthy Communities Partnership, September

2007, Client Journey Through the Primary Health Service System, September 2007

Heenan, F, Primary Care Partnership 2009, Chronic Conditions Client Journey Project: Rural

Clients’ Experiences of Chronic Conditions Living in the Portland and District, September 2009

Walker, Dr C, Chronic Illness Alliance, 2009, Helping people on the Mornington Peninsula

manage their chronic health conditions effectively - An in-depth exploration of client needs

for effective disease management in the catchment area of Peninsula Health. Report to

Peninsula Health, January 2009


ABBREVIATIONS ACAS Aged Care Assessment Service

ASM Active Service Model

CC Care Coordination

CCP Care Coordination Plan

CIYC Care in Your Community

CP Care Planning

DH Department of Health

FMPPCP Frankston Mornington Peninsula Primary Care Partnership

GP General Practitioner

PGPN Peninsula GP Network

GPV General Practice Victoria

HACC Home and Community Care

HARP Hospital Admission Risk Program

HSD Human Services Directory

IC Initial Contact

ICDM Integrated Chronic Disease Management

INI Initial Needs Identification

MBS Medicare Benefits Schedule

SACS Sub-acute Ambulatory Care Services

SCTT Service Coordination Tool Templates

SSR Service System Redevelopment

SM Self Management

TCA Team Care Arrangement

VSCPM Victorian Service Coordination Practice Manual


TERMINOLOGY47 ASSESSMENT

Assessment is a decision-making methodology that collects,

weighs and interprets relevant information about the

consumer. Assessment is not an end in itself, but part of a

process of delivering care and treatment. It is an

investigative, often incremental, process using professional

and interpersonal skills to uncover relevant issues and to

develop a care plan. Better Access to Services: A Policy and

Operational Framework identifies three types of

Assessment:

• Service Specific Assessment, where consumers have a

relatively straightforward, obvious and distinct need

• Specialist Assessment, where the presenting issues

require a specialist service response

• Comprehensive Assessment, where the consumer has

multiple or complex needs or the situation is unclear

and a comprehensive approach is indicated.

Service providers typically conduct Assessment relevant to

their services type or particular discipline. For Assessment

requirements, refer to program specific guidelines.

CARE PLANNING

Care Planning is a process of deliberation that incorporates a

range of existing activities, such as: care coordination, case

management, referral, feedback, review, re-assessment,

monitoring and exiting. Care Planning involves a judgment

and determination of relative need as well as competing

needs, and assists consumers to come to decisions that are

appropriate to their needs, wishes, values and

circumstances.

Coordinated Care Planning between services is particularly

important for people with chronic and complex needs.

CARE

PLAN/TREATMENT

PLAN

A plan which documents issues and problems for a

consumer, goals and actions that will be taken to achieve

these goals, and identifies a key worker responsible for

liaising between services. Typically developed for consumers

with complex needs and multi-service involvement.

CARER (UNPAID) A person who, through family relationship or friendship,

looks after a frail older person or someone with a disability

or chronic illness. Carers look after these people in the

community or in their own homes (DoHA, 2006).

GENERAL PRACTITIONER

General Practitioner (GP), Doctor

HEALTH SERVICE Health Service in accordance with the Health Records Act

2001, means:

an activity performed in relation to an individual to assess,

maintain or improve the individual’s health or to diagnose or

treat the individuals illness, injury or disability

47 Sourced and adapted (as appropriate for this report) from: Primary Care Partnerships, Victoria, Victorian Service

Coordination Practice Manual 2009 – pages 7,56 & 57


a disability service, palliative care service or aged care

service

the dispensing on prescription of a drug or medicinal

preparation by a pharmacist.

INITIAL CONTACT

Initial Contact is the consumer’s first contact with the

service system. It is an important function of every service

provider and usually includes the provision of accurate,

comprehensive service information, including health

promotion literature, and facilitated access to Initial Needs

Identification.

INITIAL NEEDS

IDENTIFICATION

Initial Needs Identification (INI) is a broad, shallow

screening process to uncover underlying and presenting

issues. During Initial Needs Identification the service

provider engages in a broad conversation about the

consumer’s health and wellbeing to identify the full range of

consumer needs, including health promotion, illness

prevention, early intervention, self-management capabilities

and restorative options. Initial Needs Identification is not a

diagnostic process, but is a determination of the consumer’s

risk, eligibility and priority for service, with the aim of

reaching a balance between service capacity and consumer

needs. The Initial Needs Identification process is sensitive to

the consumer, their needs and the service setting. The

service provider must use judgment and discretion to decide

the extent and intensity of the process. The gathering and

analysis of information through Initial Needs Identification

reduces consumer risk and informs the urgency and type of

assessments required.

KEY WORKER (Also may be a Care Cooordinator or Case Manager)

The nominated person who works with the consumer and

carer and other services to facilitate intra-agency or inter-

agency Care Planning and care coordination.

PRIMARY CARE

PARTNERSHIP

A Primary Care Partnership or PCP is a group of services that

has formed a voluntary alliance to work together to improve

health and wellbeing in their local community

PRACTITIONER Health professional, registered nurse, social worker,

psychologist, key contact worker, care coordinator, allied

health professional, case manager, carer support

coordinator, counselor, welfare worker, community care

worker, housing worker, clinician, and so forth.

REFERRAL

Referral is integral to working with many consumers and

may occur at, or result from, any stage of Service

Coordination. Referral is the transmission, with consent, of a

consumer’s personal and/or health information from one

service provider to another for the purpose of further

assessment, care or treatment.


SELF-MANAGEMENT The consumer (and family/carers as appropriate) working in

partnership with their health care provider to:

• know their condition and various treatment options

• negotiate a plan of care

• engage in activities that protect and promote

health

• monitor and manage the symptoms and signs of

the condition(s)

• manage the impact of the condition on physical

functioning, emotions and interpersonal

relationships.

SERVICE PROVIDER Community service organisation, non government

organisation, local government, primary care service

provider, member of Primary Care Partnership, organisation

providing services to improve the health and wellbeing of

consumers.

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.

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. Service Coordination is underpinned by

the following principles:48

48 Better Access to Services: A Policy and Operational Framework, p. 9–13, DHS June 2001.


APPENDICES


APPENDIX ONE

REPRESENTATIVE COMMENTS - CLIENTS The following are representational comments made in the course of the focus groups

discussions. They reinforce the findings listed in the report. The comments have been

kept within the relevant categories and questions to which they relate.

ABOUT MANAGING YOUR CONDITION 3. Do you feel you have been given sufficient information about your

condition/illness to manage it?

� I don’t get looked after properly

� not in psychiatric ward or elsewhere

� no-one seems interested-foot is really really painful-with a pin in it

� post polio

� I have a very good GP

� enquiring may broaden knowledge

� medically yes-well informed / practically-NO

� depends on husband greatly

� have a problem with memory which I manage with help from my family.

� It took ages-6 weeks, service provider didn't manage properly, did all I was

supposed to ………

� keep asking-older I get the more forward I get

� no issues beyond leg

� books from Council re services

� wear and tear of nursing for 47 years-I know about it

� condition is progressive so advice is sought on an ongoing basis

� oodles of paperwork

� medication for Parkinson’s

� but I've done heaps myself. Dr who diagnosed original was especially good

� from GP

� I can ring diabetes person or Nurse On Call at any time if I don't know what to

do

ABOUT GETTING INTO SERVICES 8. If you have used a service in the last 12 months, from the time you contacted

the service how long did it take to receive help?

� 1 1/4 years to get equipment

� all appointments within a month

� approx. 3 months for podiatrist,

� dental-12 months

� good for all but podiatry

� GP only there 2 days/week, hard to get appointment but tells me to ring other

Dr's there if an urgent problem

� changes depending on the type of service

� usually quickly (friend is very assertive)

� wheelchair work six months wait also and equipment


9. If you have used a service in the last 12 months, were you offered information

when you first used the service?

c. Describe what was useful and what was not useful?

� advised when I would be able to access services-cost etc.

� I work in the health system. I have been well able to navigate the service

system in terms of meeting my mother’s needs. I am not sure I would be so

confident were I not in health system

� Case Manager is very good

� didn't talk down to me like an imbecile. Felt I was treated properly

� easy to understand and helpful

� GP gave information and explained everything

� immediate, helpful for surgery

� information appropriate and necessary for my condition. Very pleased with

service

ABOUT WHAT HAS BEEN DONE TO HELP YOU MANAGE YOUR

CONDITION 11. Do you have a treatment/care plan(s)?

� asthma,

� if so my daughter would know

� medication

� my ex-wife may have it. There is a written contract but I don’t have it

� my own plan-I belong to Bushwalking Group and walk 10 km /week

� Physio plan with my back and exercises

a. If Yes, do you have a written copy of your treatment/care plan(s)?

� Case Manager would have one

� I want it amended to be suitable to my needs

16. Do you have someone coordinating your care?

a. If yes, then please indicate who coordinates your care.

� GP - very busy-often superficial attention

� I didn't know you could get so much help

� very hard to find a doctor in Mornington. I had one for 40 years and have had

about 6 since then-they keep leaving me. Don't know about Care Plan. Just do

medication.


24. What do you expect when you contact a health service for the first time?

� A full frank and honest appraisal

� Accurate information

� Advice

� Consideration

� Always had good experiences for first time. Expect to take note and time

� Assistance

� Attention-care-information

� Civility and respect

� Clear pathways to assistance so that I know what to expect

� Consideration, sympathy, positive action plan for recovery

� Decency

� Help

� Expect service and good feedback

� Expect them to listen to me

� Expected some mental and physical HELP for my situation. I couldn't face

anyone-kept crying…………….

� For them to recognise why I'm bothering to contact them and to get back to me

(they often don't)

� Good and honest service

� Help and advice

� Help in the area of need. Case Manager to organise it for me

� Hope

� Information

� Information and support

� Interest and questions about the complaint

� Careful and full diagnosis

� Full explanation of the cause and treatment of the complaint

� Listen to all

� Make me feel I am worth listening to

� Pleasant greeting and helpful doctor's advice

� Problem will be diagnosed and treatment prescribed

� Prompt replies

� Satisfaction on all accounts

� Service

� Show an interest in your problems

� Smooth entry-don’t want 3rd degree

� Support

� Time to explain to doctor about condition. Explanation given to patient about

problem and about medication. If possible, not too much waiting

� To be given precise and correct information as to how I can be helped and

(hopefully) a timely appointment if one is needed

� To be helpful and willing

� To be listened to

� To be prompt and considerate in advice

� To be treated properly and with respect

� To be treated straight away

� To get help with my symptoms.

� To be treated professionally.


� To help me

� To speak to a polite, articulate person who can answer my questions

25.What do you expect of the health service system generally?

� Accuracy-Action-Resolution.

� All I hope for is to live a healthy life ….. Treated with respect. Lots worse off than

me. Lots of places do need a better health system. I do think the public system is

very good

� Attention to my problems as early as possible

� Availability when needed

� Can be improved

� Common decency / respect

� Confidentiality / Access / Friendly staff

� Consistency in access between agencies

� Consistency in service levels between agencies

� Consistency in information provided between agencies

� Diagnosis and treatment given in a timely manner

� Expect service e.g. GP to be available when you need it

� Good honest and quick service

� Got to wait-got to get to know right people-who you know

� Happy with system

� Help

� Help to remedy some ailment

� I expect my needs to be dealt with effectively

� I expect nothing generally. I am responsible for me but they are responsible to

respond to me and my requests / needs. If they have a system they should follow

it.

� I expect to be looked after

� I expected a magic pill. Daughter died 36 years ago. After 12 months or so.

� More help

� More understanding from nurses and hospitals about care of the disabled,

communication difficulties, not involving carers enough or talking to the disabled

persons

� Not to be put on waiting lists for too long

� Ongoing diagnosis and treatment of condition within a reasonable time. Available

for all

� Prompt friendly care

� Prompt reaction

� Quality care with graciousness and politeness

� Reasonable access to whatever service required. More facilities localised.

Availability of service provider within the vicinity……….

� Service

� Support

� Support and access to information about health concerns

� That it meets the needs of those in poor health without undue delays

� That problems that arise be dealt with as soon as possible

� To be able to have my problem attended to in a professional and timely manner

� To be cured and get better

� To be prompt with attention to my needs


� To be treated as an intelligent person, not stupid, just because I'm old

� To be treated when I want to be

� To be treated with respect and for them to believe what you're saying. Happens

most of the time

� To follow through with my medical problems

� To help me

� Useful when I need them

******************


APPENDIX 2

REPRESENTATIVE COMMENTS - SERVICE PROVIDERS The following are representational comments provided by service providers in the course

of completing the survey questions. They reinforce the findings listed in the report. The

comments have been kept within the relevant questions to which they relate.

ABOUT OUR AGENCY 15. Identified Client Groups. The responses reflect a broad diversity of client groups serviced by providers.

• Aged Related Illness

• A wide range of client groups

• Adult metal health clients

• Aged and Disability

• Any client who has sustained or is at risk of falls and resides in the

community

• All areas of chronic disease

• Carers across all sectors including Disability, Mental Health and Aged

(includes a specialist Dementia and Behaviour Team and a Respite Booking

service), from all backgrounds including Aboriginal and Torres Straight

Islanders and across all ages (8 to the late 90's).

• Carers of someone with a diagnosis Mental Illness

• Children aged 4 years and older, adolescents and adults all of whom have

been affected by sexual assault or family violence (victim, family member

or support person)

• Children/adolescent counselling services

• Children's Services Focus-vulnerable families and children

• Chronic Disease and Aged Services

• Clients 16-64 with a Diagnosed Mental Illness

• Clients diagnosed with a Psychiatric Disability

• Clients over 65 years who have been assessed by ACAS Team as

appropriate for CACP Package

• Clients over the age of 65 with a mental illness

• Diabetes, Cardiac, Obesity

• Disability

• Disadvantaged and people in crisis

• Early Discharge from a Public Hospital

• Early Intervention in Chronic Disease

• Frail Aged and people with disabilities and their carers

• Frequent presenters to ED and hospital regardless of condition

• Frequent Presenters to hospital and those with Chronic Disease and / or

Complex Needs

• HACC eligible people

• Linkages

• Main focus is adults with chronic illness or disability who require case

management and brokerage to remain living in community. Children and

aged are also eligible and some receive services however aged care

services and disability services also offer brokerage and case management

to these client groups.


• Main focus is on adults with complex care needs due to chronic health

conditions, frail aged, disabilities and dementia. Linkages provide some

support to disabled children where disability services are unable to meet

their needs.

• Only if these clients have presented more than once to the health service

and are at risk of representation

• Over 65 yrs wanting to remain in their own home. Assessed by ACAS as

Low Care

• People in crisis and requires community information

• Post surgical procedures with deconditioning aspects post ortho surgery

falls clients older deconditioned clients post prolonged inpatient stay post

neurological events ABI clients post accident injuries.

• Primarily aged population but we are receiving increasing numbers of

referrals for younger clients. We do not have any age restrictions for our

service.

• Residential care

• Schizophrenia

• Serious Mental Health diagnosis

• Socially Isolated Older adults, Dementia and Acquired Brain Injury.

• The above criteria relate to the Chronic Disease and Aged Services (Both

children and older adults depending on the area of community health you

work)

• Those requiring time limited outpatient type rehabilitation or home based

rehabilitation if there is a need for contextual rehabilitation or an inability

to access centre based therapy

• We work with predominantly over 65 who have a multitude of medical

issues. We also have targets around CALD, Veterans, Dementia &

Financial & Social disadvantage

• Work with clients with mental illness but not diabetes. Also have a role

with clients with Dementia with behavioural and psychological symptoms

(BPSD). Clients with severe depressive or anxiety symptoms.

• Young people who are socially isolated

ABOUT OUR STRUCTURES & PROCESSES Whilst the distinction between information (this question) and service (following

question) was identified, a number of comments to both questions 18 & 19 also

referred to each other and are closely linked in thee responses.


information for our clients.

Comments reflected a diversity of experience, view and opinions:

� There is an integrated intake worker position for all new referrals

� central point of intake, well resourced, qualified trained intake workers

� could be improved, deficits for some particular client groups (not just at this

service)

� service wide triage service

� too confusing at present with multiple entry methods and not good protocols

across the various units (current project underway to address)

� our access and intake structure is not really geared towards the needs of young

people (13 -19 year old)

� certainly intended to do so - there are glitches


� time does not permit the staff to provide a streamlined integrated access to

information, they do their best but we are understaffed and it is a very stressful

busy role. Frequently elderly people are a challenge to keep on track (as to

why they are calling) on the phone.

� no designated Intake Worker - Case Managers are rostered to cover intake

calls. It is the responsibility of the Intake Worker to provide where ever possible

the requested information, or refer on to the appropriate agency. Clients would

only speak with Intake if their Case Manager is not available.


services for our clients.

� an area of improvement in progress with the development of a single point of

access

� can be variable and depend on staff interpretation of need

� in the most part but not if a range of services are required beyond the access

unit first contacted

� we do not deal directly with clients until they have been assessed by ACAS and

placed on S2S w/list. When a client has accepted a CACP package it is the Case

Managers job to set up a Care Plan and broker out services.

� intake staff undertake the initial SCTT and elicit any pertinent assessment

information. If referrals to external agencies are required immediately, they

provide information to the caller.

� significant focus on residential care staff to up-skill in these areas

� yes, we have good referral pathways internally and externally. However

sometimes people who need multiple services - can easily double up on

referrals. Having a key worker can decrease this "doubling up".

SERVICE ACCESSIBILITY 22. The time frame within which our clients are seen by a practitioner from the time


Whilst nearly all agencies indicated that clients / patients are seen according to

need there exists a wide range of timeframes. However, this is to be expected

given the diversity of service providers (and services).

� According to risk assessment / priority of access

� maximum time to respond to a call is 2 working days. Average time for

response is 1 working day.

� varies from same day to 3 months according to which service the client requires

varies depending on the service requested and current wait times

� telephone contact same day

� patient is contacted by phone within 3 working days of referral being processed

by intake if priority 1 (urgent) and 10 working days if the referral is priority 2

(non urgent). How soon the client is seen face to face is determined by the

client and the care coordinator. Usually the first face to face contact is made

within a week from first contact by their allocated coordinator.

� within 10 working days

� varies across the sites and across disciplines

� Care Managers visit the client - do a series of 14 assessements (incorporating

the carer) - devise a care plan in conjunction with client and their key

stakeholders, then implement agreed services and monitor.


� if the call is 'urgent' or the person is in clear distress, the issue is addressed the

same day

� between 1 -4 weeks:

i. clients judged "urgent" by ACCESS team are seen within a week or

so;

ii. people can phone or walk in. they are dealt with on phone or on the

spot and usually given an appointment time to return for

counselling at tht initial contact.

� we would always have seen people within a month of the referral, and usually a

two week wait for assessment would be considered to be too long of a wait

� intake response is same day 1st face to face contact if required will be within 2

weeks unless it is deemed that a more urgent response is required

� due to increasing demand for service our waiting period is currently 4 to 5

weeks. However all clients are triaged according to risk and urgent clients will

be seen within 1 week.

� we have a waiting list for our programs. New clients are picked up when we

have vacancies. Initial assessments are usually completed within 1-2 months.

24. Our appointment scheduling timeframes are:

Whilst nearly all agencies indicated that clients / patients are seen according to

need there exists a wide range of timeframes definition and application.

� at present we are able to meet demand based on number of referrals received

� all clients have a minimum monthly contact

� depends on the service required

� no idea how access work the priority system or even if there is one

� there are not really scheduling time frames with community health due to the

fact that we don't often get a lot of very urgent referrals

� people with highest need have priority but contact times depend on effective

communication between prospective clients, referrers and staff

25. Our clients would know that they are eligible to receive services from our

agency within what timeframe?

This question also resulted in a broad diversity of responses from agencies:

� as advised by worker on the day - this can change daily and each service is

different

� as most referrals are generated by Peninsula Community Mental Health Service,

eligibility has already been established. Access to preferred activities or groups

is dependent on availability and is variable.

� as soon as eligibility is determined, no time frame

� clients receive a letter saying that they can access Duty worker whilst waiting

for initial assessment

� contact from our service is usually within 10 days from referral. That contact is

usually a phone call.

� dependant on assessed need by triage service

� Generally on the day of assessment unless the Case Manager has concerns that

we could not meet our duty of care and/or has concerns re; risk. In this case

would usually take closer to 7 days (but the client/family would be informed).

� General Practitioners refer to our service-they provide this information

� I suspect they don't (know) this at all as it isn't communicated that way, we

tend to send a letter saying you are on the wait list for x date.


� I'm not sure whether clients know that there is a timeframe, we just book them

in whenever we have a free spot

� it depends upon the level of risk and the type of service required. E.g. domestic

care, personal care, meals on wheels, social support/community transport,

respite care, home maintenance.

� patients are contacted by the intake worker upon referral to the program to

ascertain consent and confirm eligibility

� there is no set time frame for provision of a service, but clients are informed of

the estimated time frame

� They don’t know

� this would depend on the urgency. Services could commence as soon as a Care

Plan has been signed. On average it takes a week or two to set up a Care Plan

and arrange for services to commence.

� unless urgent. We also have a waiting list

� usually they are told the waiting times when they call access. Uncertain if they

have any assumptions regarding the timeframe they will need to wait.

ASSESSMENT & CARE COORDINATION

50. We normally ask for our client’s consent to allow our services to access and

share their personal details and health information with other service providers.

� consent form must be signed before contacting any service provider on behalf

of the client. Consent Form is continuously updated when necessary.

� when referring to another agency

� initial consent is written but ongoing consent is usually verbal

� must fill out client consent for release of information form at all first visits

� signed consent is obtained prior to dissemination / sharing client info with

external service providers.

� under Mental Health Act sect 120a we are able to share relevant information

with other health professionals when required for a client’s care. We do

however usually seek the consent of the client first.

� usually only when corresponding with GP

� we have a very detailed client agreement containing consent form signed at

commencement of the package - this can be reviewed any time at request of

client. We send GP's a letter to let them know client commencing on a package

with our service. Can be hard to engage GP's.

� we have consent to discuss support given by program with referrer and clinical

services

52. Our organisation has a system for recall, reminder, monitoring and review of

care plans.

� all care plans are reviewed at least 3 monthly with a major review every 12

months. This process has quality certification and close monitoring via quality

management systems.

� we have a system but are not resourced to deliver reviews as required under

HACC funding

� scheduled client review

� all care plan reviews required 6 monthly. Can be ascertained by looking at

client's file. Care Managers have to report at end of month on their clients and

when care plan review due also.

� ……..but clients are rarely reassessed at the 12 month mark due to high

workloads and staff shortages


� only if repeat assessment appropriate- usually after 12 months

� care plans are reviewed as necessary during the year. A formal Assessment

Review is carried out every 12 months. This is monitored during Supervision.

53. We contact our clients for follow up/recall appointments/reviews.

� based on feedback from direct care staff re change of circumstances or from

GP/family members. Not regular planned reviews as we are not resourced to

do this.

� clients are contacted on an ongoing basis regarding their care needs with a

minimum Case Manager initiated contact every month and home visit/review

every 3 months for clients whose care needs are stable.

� clients must be visited on a 4-6 weekly basis, with phone contact in between

� not follow up after discharge but within the episode of car

� reviews are done with clients present

� should happen at least annually but this frequently does not happen because

staff are so busy with other clients

� we conduct a 6 week phone review but find it difficult to keep to this time frame

due to the high demand for new assessments

� we will contact either by phone or do a home visit - whichever is seen as

appropriate - according to urgency and priority

54. Our client records indicate that planned reviews have occurred within one month of the date listed for review.

� clients are not always contactable

� decision on when to review depending on their goals and level of support they

would like

� if a client is unavailable for review within one month of the listed date, this is

documented within the client record and a review is rescheduled for the earliest

possible date

� simply cannot review all 3,000 of our active clients

55. We offer information and support through the provision of self management

opportunities to our clients to help them manage their condition/situation.

� depending on the clients capabilities to do this

� services are arranged in such a way as to encourage client to self manage

� the focus of a CACP Package is to keep the client at home and independent as

long as possible, if that is their wish

� the offer is there, but clients may not take it up

� we work in the Early Intervention in Chronic Disease program therefore we

constantly want to enable people to self manage their condition in the future -

that is our aim

57. What could be done to improve coordination between our agency and

other service providers?

There is remarkable coherence across the responses from a diversity of

organisations. These have been collated and identified into three distinct

categories:

A. Improved technology

B. Improved system wide and coordination

C. Improved client specific referral, communication and coordination


Comment

A

Technology

B

System wide

coordination

C

Client specific

referral,

communicat’n

&

coordination

More feedback to agencies involved in client care ��

Improved discharge planning from hospital back

into the community. Discharge is sometimes

brought forward without notice or Care Managers

are not notified or client admissions.

��

Fragmentation of service system has led to a

much higher number of programs/service

providers. Makes it very difficult for all agencies

and practitioners to remain well informed of other

services and to undertake good service

coordination. Mechanisms to assist these aims

would be useful ie a single directory of

services/programs, regular forms (sub regional)

for service providers.

��

Better referral system to allow service providers

to communicate more information regarding the

client.

��

Electronic medical records, so practitioner can

access patient's medical history. ��

Better communication and acknowledgement that

the referral has beeen received. ��

Improved understanding of the role and better

General Practitioner engagement. ��

Common assessment form with ability to use

email. ��

Mechanism for Electronic Referral for External

Agencies. ��

Easier access for referral. �� Being able to get feedback from agencies we refer

clients to - this is not automatic with some

agencies.

��

Liaison with psychiatric services could be

improved. ��

Better protocols for communication and sharing

information such as care plans more readily. ��

Increased communication. ��

Single IT software Defined Access point. Clear

eligibility criteria. ��

More work around transition, for example, council

to packaged care. More involvement from General

Practitioner's, many who have limited knowledge

around packaged care. The RAD team at

Franskton hospital was a great innovation and has

improved communication between acute and

community sector.

��


Comment

A

Technology

B

System wide

coordination

C

Client specific

referral,

communicat’n

&

coordination

We need more face-to-face with other agenices -

joint visits, time for case conferencing etc. ��

Professional Development sessions offered re up-

to-date service info with relevent agencies;

newsletter/bulletin board to disseminate service

info and updates to member agencies; "open-

house" sessions offered for staff to visit various

member agencies; facilitate the role/importance

of secondary consults between relevent agencies;

clarity of referral pathways and criteria.

��

More information about services and contact

people. ��

We get no feed back from ACCESS when we make

referrals, MEPAC’s is the only service which gives

us written feedback, other wise we have no idea

(unless we ring ACCESS) if the referral has been

followed through and the client seen.

��

Improved networking / training opportunities

opportunities for clinical staff - constrained by

having to work 80% clinical. Clinical staff to be

more involved in service development with other

agencies - not just left to managers.

��

Networking with other agencies on a regular

basis.e.g. ACAS/HACC/ Package Provider

interface. This has provided an opportunity for

participants to work together to improve outcome

for clients

��

Better knowledge of services that are available in

the community and how to refer in to them. ��

Shared information on Discharge planning etc �� Clear of what other service providers a person is

involved with. Not always disclosed. ��

Clarification of roles and more inter agency

meetings or feedback. ��

Technology and more conversations with

appropriate service providers. ��

Continued communication between workers. ��

REFERRAL & FEEDBACK 65. We have a process for communicating with GP’s.

A number of agencies identified contact with GP’s as being one way and on an ‘as

needs’ basis. In addition the following Representative comments were made:

� Care Managers attend client appointments where necessary or send relevant

information to GP


� always write a letter to any GP who has referred a client, will ring the GP to

discuss clients if I feel it's necessary or more urgent

� no set process, it is up to the individual clinician to find acceptable ways to

communicate with GPs. They remain reluctant to talk or provide support or

entire into partnership with their clients care

� send GP letter when client commences on a package:

• contact GP if any concerns regarding client's health status

• contact GP to request referrals to other services

• looking to employ a clinical nurse to enhance this communication

� standard practice is to obtain the clients consent to contact GP. A request for a

medical summary is faxed to GP. A letter and copy of care plan is subsequently

forwarded to the GP

� no formal process. HACC services are not regarded by GP’s as a health service

so we are less likely to be involved...however we see clients regularly in their

own homes and can perform a valuable monitoring function which GP's probably

are not aware of.

� standard letter sent to GP when a client accepts CACP Package. The letter

introduces Case Manager, explains what a CACP Package is

� have an intake worker who deals with most of this process

� normally send GPs a letter following assessment of clients or with updates

following reviews and of changes in treatments or with recommendations to the

GP

� we usually ring to discuss issues or send a care plan

• communicate with GP with client's permission as needed

• with client consent we contact for confirmation of diagnosis, or for ongoing

contact if appropriate


APPENDIX 3

CLIENT PATHWAY INFORMATION

58. Please provide a brief description or simple diagram of the general

client pathway and through your organisation.

These pathways have been submitted by service providers and provide an

indication of the diversity of systems and practices relating to client access to

services and the care coordination processes supporting the client with the

health care system.

Referral via Intake by health agency including GP, family or community.

Access/intake initial needs assessment appointment with appropriate

clinician.

Client calls Service.

Call put through to access worker.

Access worker provides initial needs identification and register client for service.

This can be allocations of appointment or allocated to a waiting list.

Clients on waiting lists may contact Access to advise of change in urgency etc - in

this case Access would re-prioritize the client accordingly.

Intake Assessment Services referrals where appropiate OHandS

checks service provision possible review by a team leader 12 months later

if client is lucky.

Intake-assesement servcies delivery monitoring review.

ACCESS receives referral and processes next contact is made by receiving

service.


Access - self refer or referred by another health provider (GP, case manager,

carer etc)

Access obtains initial baseline information and determines where best to refer the

client (health prof within service, or group, or different services within Pen

health).

They are then booked into the appropriate service.

All newly diagnosed people with chronic disease (i.e. diabetes, cardiac, pulmonary

etc) are usually placed straight into a group program if appropriate for an

introduction.

Then they will be placed into the Early Intervention in Chronic Disease program.

This means they have a 1:1 comprehensive assessment with a key worker, and

they then decide together what the client goals are and devise a care plan.

Any internal/external referrals are completed to appropriate services to help

achieve these goals.

Key worker follows client up at 3 months (phone review), 6 months and 12

months (1:1 reviews if possible) to review goals and provide any other support -

aim being to encourage and empower client to better self manage their own

chronic disease by the 12 month stage.

Clients attend every week for 1-2 daily and /or overnight sessions of social

support and carer respite and generally stay until admission to residential care.

ACAT assess client listed on e-waitlist picked up by package provider

case management and services delivered into the home, usually until no longer

sustainable and client discharged to either higher level of pacakge, residential

care or dies.

Client or referring agent contact or triage worker.

Case is discussed with team the following day.

Decision made re acceptance for service or not.

If not recommendations may be given.

Clients seen according to urgency Usually within 2 weeks.

Client will have face to face assessment and either accepted for ongoing

treatment or given other options.

Following treatment will be linked with other service providers prior to discharge

from the service.

Intake care coordinator linkages to community.


Assessed by ACAS Team and if appropriate placed on S2S w/list.

Team Leader access w/list when Case Manager has a vacancy and contacts

client/family is ascertain if they are interested in taking up package.

Client is then allocated a Case Manager who will ring client within 24 hrs and

arrange a Home Visit preferrably within 7 days to complete paperwork.

A Care Plan is devoloped with the client/family. Services are brokered out to

appropriate agencies and commence on an agreed date.

Care Plan is monitored and adjusted as required. Formal Review on annual basis.

Client discharged from program - deceased, Resi. Care, referred to a higher care

package e.g. EACH.

Referral received.

Referrer and Carer contacted by Duty intake worker (Initial Screening for

eligibility).

Weekly Joint Intake discussing referrals with Commonwealth Respite and Carelink

Centre.

Worker allocated if vacancy, or put on wait list.

Carer is contacted and advised.

Carer Assessment completed with new worker, and support commences.

If referral is not appropriate, referrer is advised as assisted to find appropriate

service.

Referral sent to Agency Initial Screening for eligibility.

Referrer/GP contacted.

Letter to Client acknowledging receipt of referral and access to Duty worker.

Appointment made for initial assessment.

After assessment client commences with program or put on waiting list if there is

no vacancy.

If client is not accepted into program they are advised. Referrals to other agencies

if appropriate


Figure 1-115

STEP 1. Service Provider or Client Contacts MPS for information and/or services via: • Fax • Phone • In person

STEP 2. RIO undertakes initial assessment of client needs: • Determines urgency • Makes relevant referrals to Council service(s) and/or

external service provider(s) • Provides relevant information

Refer to other service(s)

External service(s) required

STEP 3. Enter personal details of eligible

clients into Carelink

STEP 4. Distribute case file to

Assessment Team

STEP 5. In Home Assessment

STEP 6. Data entry following assessment/

re-assessment

Meal set up in Carelink

Meals Referrals

Meal Produced

Meal Delivered

Refer clients to other agencies and/or allocate

services internally

STEP 7. Refer clients to other agencies

and/or allocate services internally

STEP 8. Commence service delivery

STEP 9. Monitor health & well being & adequacy of service provision

STEP 10. Review/re-assess client via

phone and/or home visit

Home Maintenance or Modifications

Referrals


APPENDIX 4 EXTRACT FROM:

FMPPCP SOCIAL INCLUSION WORKING GROUP SERVICE PROVIDER SURVEY -

SUMMARY OF FINDINGS, OCTOBER 2010

Below is a summary of the results which mirror several findings in the Client

Journey study in respect to issues relating to social inclusion – including

transport.

The Social Inclusion Working Group was established by the FMPPCP’s Health

Promotion Collaborative to achieve the following goal:

“People are connected and have a sense of belonging to the wider community”

Under this goal, it is the aim of the FMPPCP that by 2012, all member agencies

will

1. Have improved knowledge of social inclusion

and/or

2. Have identified social inclusion as a priority in their plans

The Social Inclusion Working Group developed a simple survey for service

providers, asking them to identify the following, based on their professional

opinion:

1. Which population groups do they think are most at risk of social

isolation?

2. What are the main barriers to these groups being socially

connected?

3. What are the main enablers that would assist these groups to be

more socially connected?

The results show only a snapshot of what is happening in the community. Upon

reflection The Social Inclusion Working Group believe the results are consistent

with much of the evidence from the FMPPCP catchment.


SUMMARY OF RESULTS

Which population groups are most at risk of social isolation?

Population Group

1

1

1

1

1

1

1

1

1

1

1

2

2

2

3

3

3

3

3

4

4

7

8

8

12

0 2 4 6 8 10 12 14

Office of housing

New fathers

Nursing homes

Homeless

Pregnant teens

Women experiencing violence

Language disorder

Middle aged, middle income

GLBTI

Obese

Chronically ill

Living alone

New migrants & refugees

Insecure accomodation

CALD

Addicts

Intellectual disability

SRS residents

Carers

ATSI

Single parents

Youth - disconnected

Physical disability

Mentally ill

Older (65+)

Series1

Based on the number of times each category was mentioned in the survey

responses, the results show that older people and those with a mental illness

were identified as being most at risk of social isolation. Of course, an individual

may fall into multiple population categories, such as over 65, have a mental

illness, an addiction, and homeless – so it is not assumed that each population

group represents a separate individual. In fact, what this clearly illustrates, is

that if an individual does fall under several of the identified populations groups,

their risk of social isolation potentially increases, giving an the above

mentioned scenario of multiple categories a possible score 24.

It should also be noted that individual service providers responses may be

skewed to identify the population group that they have the most contact with,

not necessarily responding with the 'bigger picture' in mind. Respondents would

not necessarily be aware of all the different population groups who experience

social isolation so this is understandable. However, this information should

be understood in the context of relevant demographic information and

community surveys which may provide a richer source of information and

definition of the population group/s most at risk of social isolation.


What are the main barriers to these groups being socially connected?

Barriers to social inclusion

0 5 10 15 20 25 30 35

Alw ays in crisis

Weather conditions

Poor nutrition

Housing affordability

Lack of childcare

Pregnancy/young parents

Disorganisation

Poor hearing/vision

Exhaustion

Body image

Limited English/communication

Physical infrastructure

Low education

Lack of positive role models

Culturally inapropriate services

Inappropriate services

Homelessness/insecure accom

Low motivation

Lack of local know ledge

Addiction

Lack of services/funding for services

Community ignorance

Violence/abuse

Ill health

Active exclusion

Low employment opp.

No internet/computer or skills

Low self esteem

Low social skills

Lack of family support

Social stigma

Lack of support netw orks

Mental illness

Financial

Transport/Mobility

Series1

The survey results show the issues of transport/mobility as being the most

significant barriers to social inclusion. Transport and mobility were grouped

together, as in most cases they implied a similar lack of ability to get from A to

B. This barrier might be imposed in different ways however; therefore

transport/mobility covers everything from lack of public transport to physical

frailty.

Transport/mobility is also closely related to the second highest ranking barrier,

“financial”. Again, a broad definition covers this group, and covers limited

individual financial capacity through to affordability of services and activities

(prohibitive costs) – not including housing.

Whilst it is out of the power of most service providers to directly increase bus

frequency or income levels, there are many other areas within the listed

barriers where it is possible to make a positive difference. There are also

opportunities for increased advocacy in these areas as a partnership.

Increasing opportunities for people to participate and engage within the

community could involve working with community groups, sports clubs,

education and service providers to increase awareness of what socially isolated


people are experiencing, and improve their capacity to be more understanding

and inclusive.

What are the main enablers that would assist these groups to be more socially

connected?

Enablers to Social Inclusion

0 1 2 3 4 5 6 7 8 9

Aboriginal community controlled servicesAboriginal advisory committees

Specialist helpMotivational counselling

Good self esteemMore income

Travel training

Improved childcareVaried housing options

Better/more facilitiesGP links to support

Friendship opportunities

Carer respiteAdvanced medication

Employment opportunitiesVolunteer opportunitiesCo-ordinated treatment

More home helpPAG

social training/retrainingVisitors

Welcoming/aware services

Free community events/groups/etcP'ships w ith community groups

Focus on strengthsHelp w ith languageSelf help services

Support groupsLocal access

Cross section of community contactApproproate activities

Community inclusion programs

Improved community attitudesSupportive families

More funding for servicesImproved services

More local, inclusive groups

Assistance w ith linking people into communityTravel assistance

Series1

Combined with the list of barriers, the enablers provide us with 39 clues about

how we can assist people to be more socially connected. We are also beginning

to see some common themes emerging i.e. The top enabler of ‘linking people

into community’ can be supported through almost all the other enablers listed

above.

It is also important to note that many of these enablers are already happening

in the community, both at a service level and through volunteers, however the

survey results indicate that there needs to be more support to reach all people

in need. So although the need maybe being met there is a perceived need

which needs to be addressed. This indicates a need for a better flow of

information about existing enablers to people experiencing social isolation

and/or expansion of enablers to accommodate more people.

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