Changing the coordinated care approach
Affecting over three-quarters of Australians over the
age of 65, chronic disease continues to be the most significant burden on our health system.
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At SEMPHN, we aim to reduce the impact of chronic disease on our hospital system by ensuring our community has the right mix of local service providers, skills, and resources to deliver better care coordination for people with chronic or complex needs.
Care coordination is not a new concept. SEMPHN’s chronic disease management program was first introduced in June 2017. We have continued to learn and adapt how we can best engage commissioned providers with the best systems, tools and supports that embed proactive coordinated care within general practice.
In 2019, our chronic disease management approach introduced the most meaningful change to our care coordination offering. When caring for patients, we know that time and dedicated health workers make a world of difference. We recognised that embedding practices that support a patient-centred approach and the wrap-around services of coordinated care takes time, so we extended the program to be delivered over two-years. The program offers general practices additional time for staff to develop individual comprehensive health plans to connect patients to the best care, when and where they need it.
Seventy-five additional local providers can now work with consumers to develop a comprehensive plan that helps people take more control of their health and achieve their goals.
Practitioners benefit from building partnerships with other providers of healthcare, social and community programs and patients. SEMPHN has taken on feedback to create opportunities for more innovative care, including telehealth, health coaching and shared medical appointments, as well as helping embed team-based approaches that enhance patient care to create more flexibility and less duplication.
A real-life case
A man who had experienced complex needs was discharged after an extended admission in psychiatric care. The care facility was a provider enrolled in SEMPHN’s care coordination program, which enabled them to quickly link the consumer with a My Aged Care assessment, arrange a home alarm, organise more home help and encourage him to get back involved in social activities.
"The patient did not want to feel like a burden on the resources of our practice. SEMPHN’s care coordination program granted a type of permission for him to have this level of care," said the patient's Care Coordinator.
Consumers receiving care coordination often report that they feel more empowered and more cared for. They say they feel more connected with their health care provider and more confident about their ability to safely stay at home.
Data driven support
Our regional data and insights help us increase service access to support communities where the need is greatest, reducing avoidable hospital admissions and the need for critical care.
Strengthening the program’s success, the ‘Care Coordination POLAR Report,’ was recently introduced to SEMPHN’s care coordination programs. Program activities are related to the implementation as well as professional development. These added insights enable us to better assess coaching and support needs for our care coordination providers. Patient activities are also captured in POLAR which highlight clinical and non-clinical activities that have been completed as well as those that are overdue. This level of detail in the reporting has supported SEMPHN’s ability to effectively monitor care coordination programs through data driven insights.
Ditching the red tape
Recognising areas of greatest need is not always aligned with who can best articulate that need in a tender submission, so we revamped our commissioning process.
Now in its third iteration, our care coordination program recently welcomed another 25 general practices into the world of care coordination, commissioned via this new process. The greater mix of candidates, who may not have applied previously to funded programs, means more choice and access for consumers where they need it most.
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South Eastern Melbourne PHN
Level 2, 15 Corporate Drive
Heatherton Victoria 3202
ABN 65 603 858 751
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