GP General Practitioner HACC Home and Community Care HIP Health Program ICDM Integrated Chronic Disease Management LGA Local Government Area PCP Primary Care Partnership PD Professional Development PDSA Plan Do Study Act PHCH Peninsula Health Community Health SSR Service System Redevelopment SSRC Service System Redevelopment Committee List of Figures Page Figure 1 Wagner Chronic Care Model Figure 2 PDSA Cycle Figure 3 Strategic Work Levels Providing Framework for SSR Planning & Work Activities References FMPPCP Strategic Plan 2009-2012, Service System Plan Review, Revised Plan 2011-2012 Mckay, Lyn. FMPPCP SSR Coordinator, FMPPCP; J. White, ICDM Support Officer, FMPPCP, Juliet Frizzell, JF Consulting, FMPPCP Broader Needs Assessment (BNA) Tool Project Pilots Report, Frankston/Mornington Peninsula Primary Care Partnership December 2011 McKay, Lyn. FMPPCP SSR Coordinator, FMPPCP; J. White, ICDM Support Officer, FMPPCP, Through the Eyes of the Client (Client Experiential Study), Frankston/Mornington Primary Care Partnership December 2010. State of , Primary and Community Health Branch, Victorian Government Department of Human Services, , Revised Chronic Disease Management Program Guidelines for Primary Care Partnerships and Primary Health Care Services, October 2008 State of Victoria, Victorian Department of Health, Victorian HACC Active Service Model Implementation Plan 2009-2011, 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 Victorian Service Coordination Practice Manual 2009, Primary Care Partnerships, Victoria, 2009
Appendices These appendices set out summaries of the mapping information. Service Providers have not been identified. Summary of Assessment Tools, Assessment Practice, Guidelines and CQI Assessment overview Organisation 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 Assessment Tool Yes Yes Yes Yes Yes Yes Yes Yes Yes No Yes Yes No Yes Yes Yes Yes Yes Yes Type of Assessment provided Comp. Comp. Service specific Comp. BNA Comp. Comp. Comp. BNA Comp. & Service specific BNA Comp. Service specific & Specialist BNA N/a Medicare Health Ax Comp. Service specific & Specialist N/a Service specific Comp. & Service specific Comp. & Service specific Comp. & Service specific Comp. & Service specific Comp. Guidelines, work instructions etc to support assessment Yes Yes - Yes Yes Yes Yes Yes Funding body specified n/a Yes Yes n/a Yes Yes Funding body specified - Yes Yes Evaluation/ CQI processes in place Yes Yes Yes Yes Yes Yes Yes Yes Yes n/a Yes Yes n/a Yes Yes Yes - Yes Yes Mapping of Assessment Tool Domains Shaded area denotes the domain is documented in the Assessment Tool Health Behaviour Domains Organisation 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 Oral health /
Summary of Care Planning Tools, Assessment Practice, Guidelines and CQI Organisation Care Plan overview 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 Care Plan Tool Yes Yes Yes Yes n/a Yes Yes Yes Yes No Yes Yes n/a Yes Yes Yes Yes Yes Yes Type of care planning Service specific Service specific Service specific Service specific n/a Service specific Service specific Service specific comp No comp comp n/a Service specific Service specific Service specific Service specific Service specific comp Guidelines, work instructions etc Yes Yes Yes n/a Yes Yes Yes No Yes Yes n/a Yes Yes Yes Yes Yes Yes Evaluation/ CQI processes in place Yes Yes Yes Yes n/a Yes Yes Yes No Yes Yes n/a Yes Yes Yes Yes Yes Yes Mapping of Care Plan Template Domains ***Shaded area denotes the domain is documented in the Care Plan Template of the organisation Domains Organisation 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 Date care plan developed Participants in development of care plan Client stated/agreed issues/problems Client stated/agreed objectives/goals
Client stated/agreed strategies/action Responsibilities for implementing strategies/action Timeframe for attainment of objectives/goals Review date of care plan Consumer Acknowledgement (signed or verbal acknowledgement recorded) Goal/Objective attainment /outcomes Summary of Referral Tools, Systems and Practices Referral components Organisation 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 Send referrals using Connecting Care No No No Yes Yes No yes No No No n/a No n/a No No Yes No Yes Yes Receive referrals using Connecting Care No No Yes via Access Yes Yes via Access No Very few Yes via Access Yes via Access No n/a No Yes No No yes Yes via Access Yes No Make internal referrals using Connecting Care No No No No No n/a No No No No n/a No No No No n/a No - n/a Make internal referrals using other e-referral system Yes S2S PJB email PJB n/a Yes PJB no n/a Yes PJB n/a Yes n/a PJB Yes n/a Referral options Phone Fax Fax Phone Fax Phone Fax Phone Fax Phone Phone Fax No Phone Fax Phone Fax n/a Phone Fax n/a Phone Fax Phone Fax Phone Fax Phone Fax Phone Fax Phone Fax