Lynette Purton, PHT

Abstract

Primary Health Tasmania’s Local has developed and implemented a comprehensive, state-wide, evidenced based care coordination program, designed for frail aged and older people with complex chronic conditions.

The main aim was to; provide client centred care that assists clients and service providers to manage all the needs required to maintain quality of life, (medically and socially) and promote health and independence.

This program was developed in response to the range of identified poor health and social factors, gaps in service delivery and most importantly in recognition of the wide variety of work that is already being completed in the Primary Health, Aged and Community Sectors.

As Michael Ferguson stated recently; “ Tasmania’s Health system is broken and needs to change”

We implemented a variety of models in different sectors and with organisations already providing client services with the aim to increase capacity and not duplicate.

Program Objectives:

• Improve the coordination of care – complex chronic disease and aged care clients
• Ensure clients have capacity to be in control of their health care
• Support improved health outcomes
• Increase access to available services
• Reduce inappropriate and avoidable service utilisation across the health sector
• Assist in preventing hospital presentations and admissions

Outcome:

Tasmania Medicare Local state-wide Care Coordination Program, non-clinical model is adaptable and enhances the capacity and scope of what is already being done in organisations and in the community. Working in collaboration with sectors and service providers, regarding client care needs, decreases duplication and ensures improved client outcomes. The key components of this model are; comprehensive assessment, reviewing medical, social, home and risk assessment, developing person centred goals and ending with a broad picture of all services and gaps. The clients’ knowledge and understanding of why, how and when to access and navigate the community and health systems and services is increased, (a little hand holding), plus they are given ownership over own care and decisions increasing their self-sufficiency, (client-centred care).