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HARP - Hospital Admission Risk Program The Hospital Admission Risk Program (HARP) was established by the Department of Human Services in 2001. It is a component of the Hospital Demand Management (HDM) strategy which aims to strengthen the capacity of the Victorian Health Service to manage increasing demand pressures. The focus of the Hospital Admission Risk Program is on prevention and its primary purpose is to enhance or develop models of care that better manage patients within the hospital and the community to prevent inappropriate emergency presentations or admissions. Southern Health and community partners now have six HARP funded projects operating. There is a Project Leader in each project area and general support and facilitation is provided by the Strategic Development and Business Support Unit for Primary Care and Mental Health programs. For more information please contact Cynthia Theobald (ph. 0414 306 705), Strategic Development and Business Support Unit. Management of Chronic Respiratory Conditions
FOR INFORMATION CONTACT: Kate Whyman Strategic Development and Business Support Unit, Primary Care 1 Raymond McMahon Boulevard Endeavour Hills VIC 3175 Telephone: 9709 7176 email: kate.whyman@southernhealth.org.au
The aim of the project is to reduce avoidable use of acute services (hospitals and emergency departments) by providing enhanced primary care through community-based services. The project focuses on provision of co-ordinated, responsive, preventative services, based in the community, with a focus upon self-management and improved cohesion of services for the target group (adults suffering chronic respiratory conditions).
Target group: These services are for adults suffering chronic respiratory conditions, such as chronic obstructive pulmonary disease (COPD), which includes chronic bronchitis and emphysema.
Service provision: The key components of the service are in the first instance improved access to services, an initial pulmonary rehabilitation program (which consists of exercise and education for the participants, their families and carers), an ongoing maintenance program after the pulmonary rehabilitation program has been completed, and finally, facilities for support groups. In addition to the broad range of services and multidisciplinary involvement, transport is also provided for those who would otherwise be unable to access the services. The development of these services has been a collaborative effort across the acute, subacute and primary care sectors, and included representation from consumers and general practitioners. The services commenced in February 2003 and are currently being provided through three Southern Health Community Rehabilitation Centres (Springvale, Clayton and Pakenham), with involvement from the Rehabilitation in the Home service and liaison with the new HDM-funded, acute-based Peak Flow Initiative. Initial evaluation measures of the services indicate an improvement in key outcome measures of the target group.
Referral: Hospital staff, community based health care service providers, including respiratory physicians, general practitioners and allied health.
Assessment: Clients assessed according to individual need.
Appointments necessary: Referrals are forwarded to the appropriate CRC, clients will be contacted to make an appointment time.
Resource Manual: Click here to view the Pulmonary Rehabilitation Resource Manual - Lungs and Lifestyle. (PDF 1MB) Health for Kids in the South East
FOR INFORMATION CONTACT: Dr Claire Harris, Project Manager Phone: 9594 7576 Fax: 9594 7552 Email: claire.harris@med.monash.edu.au
Aim: The Health for Kids project will improve health outcomes for children and young people in the Southern Health catchment area by:
Location: Monash Institute of Health Services Research, Level 1, Block E, Monash Medical Centre, Clayton.
Office hours: 9.00am – 5.00pm
Catchment area: Southern Health catchment area.
Care in Context
FOR INFORMATION CONTACT Anne Parkes 95548744
Aim: Care in Context aims to better manage clients with complex and/or chronic conditions by improved co‑ordination provided at the acute and community care interface.
Target group: People who are frequent presenters to the Southern Health Hospital Emergency Departments.
Service provision: Clients are referred through the acute hospital system. They are provided with a thorough assessment, and short to medium term care coordination. Strengthening links with between the acute and primary care sectors, and client self management strategies, are significant aspect of Care in Context.
Location: Head Office ‑ Dandenong Hospital. Staff are based at locations in Cardinia/Casey, Greater Dandenong and the Middle South.
Office hours: 9.00am to 5.00pm, Monday to Friday.
Catchment area: Cardinia/Casey, Greater Dandenong and the Middle South
Referral: Through the acute hospital system
Special requirements: Must have a Care in Context Alert on their Southern Health Acute Hospital Medical Record
Assessment: Clients assessed according to individual need
Appointments necessary: Appointments are made by the Care in Context Care Consultants
Supporting Improved Management of Chronic Heart Failure in the Community
FOR INFORMATION CONTACT Chronic Heart Failure Nurse Co- coordinator: Elizabeth Everard Telephone: 9554 1837 Email: elizabeth.everard@southernhealth.org.au
Aim: The purpose of the Chronic Heart Failure (CHF) program is to support improved self-management of CHF in the community. Specifically the program aims to improve quality of life for clients, reduce the need for re-presentations for an exacerbation of CHF or, if the client does need to represent , the length of stay for that hospital admission is shortened.
Target Group: The target group for this project initially includes those who present to the Emergency Department and who have been admitted to Southern Health more than once in a twelve month period with a primary diagnosis of chronic heart failure and those identified as a high risk of readmission. In time, the target group will be expanded to include direct referral from local general practitioners and cardiologists, who are currently being contacted to inform them of the CHF program.
Service provision: The initial contact is principally through visitation by a specialised CHF nurse in hospital who provides education and written material for the client and their carer/families as well as facilitating support and rehabilitation services as required. In the first week following discharge from hospital the client receives a phone call or home visit to see how they are managing their CHF. Following this there is a specialised CHF clinic for the client to attend within a month of discharge. Three and twelve month reviews at the clinic are also offered. This clinic is based at Dandenong Hospital. At each successive stage the clients’ information is passed on to relevant stakeholders to maintain communication. The role of the CHF program is to assist and support the management undertaken by the general practitioner and cardiologist.
Location: CHF Nurse Coordinators office: 128 Cleeland St, Dandenong 3175 CHF Clinic: Tuesday afternoons at 128 Cleeland St, Dandenong 3175; 1.00pm-4.00pm
Office hours: 9.00am – 5.00pm Monday - Friday
Catchment area: Clients in the Southern health region
Availability:
Referral: Hospital staff, general practitioners, cardiologists, other CHF programs, self referral
Special requirements: Client has a known diagnosis of chronics heart failure
Assessment: Clients assessed according to individual need
Appointments necessary: Appointments required for the CHF clinic only
Acute Primary Care Liaison (G.P.)
FOR INFORMATION CONTACT: Dr Sharon Monagle, GP Consultant 9594 2732
Aim: The program aims to bring a GP perspective to Southern Health's strategic planning processes, address issues impacting on the acute primary care interface and to build and maintain strategic and working relationships with GPs, Divisions of General Practice, GPDV and the GP advisor to DHS. It further aims to build a culture of shared understanding, respect and cooperation between the acute and general practice sectors and effect systems and culture changes that will provide for sustained improvements at the interface between hospital and general practice.
Location: Monash Medical Centre, Clayton
Target group: All patients, their GPs and the Divisions of General Practice within the Southern Health catchment area.
Medication Alert
Janice Jones Telephone 9207 1036 Email: j.jones@alfred.org.au
Aim: Medication Alert Project is a collaboration of Austin Health, Bayside Health, Melbourne Health, Southern Health and Royal District Nursing Services (RDNS). The aim of the project is two fold, both to implement strategies to improve patients understanding and compliance with their medications after discharge from the hospitals and also to improve communication with the patients GP and Community Pharmacy to prevent medication related problems. The strategies include pharmacists based at the hospital visiting patients after discharge, referrals for Home Medication Review and medication assessment by RDNS.
Target group: The target group for the project includes patients who are taking multiple medications and who have had a number of changes to their medications whilst in hospital as well as patients who are taking specific drugs or regimens which are complex and may increase their risk.
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