Page 4297 - Week 12 - Thursday, 24 October 2019
Next page . . . . Previous page . . . . Speeches . . . . Contents . . . . Debates(HTML) . . . . PDF . . . . Video
The objective of the report’s proposed model is to address and remove barriers preventing a smooth transition between hospitals and the community for people with chronic and complex conditions. The report describes barriers to patient care navigation and outlines key principles criteria for a successful service and intended outcomes.
The report’s findings are informed by examples of care coordination in hospital, and the community, two patient care navigation case studies and interviews with health professionals and consumers. It also provides background on patient care navigation and recommendations for governance, IT and work force requirements to implement a successful model. These examples will be useful as the ACT Health Directorate completes further policy work in this space.
In researching patient navigators, the HCCA reviewed two services operating in other jurisdictions: the Queensland Nurse Navigator Service and the Western Healthlinks Service operated by Silver Chain Group in Victoria. The Queensland model is led by senior nurses and has an open referral system. The service provides end-to-end care with key aspects including advanced hospital discharge, nurse-navigator-led outpatient clinics and coordinating patient and caregiver care. Navigators are based in hospitals and community health centres.
By comparison, the Victorian Western Healthlinks Service is primarily operated out of a central office by health navigators who are registered nurses or allied health professionals. Patients are identified through an emergency department algorithm that targets high users and frequent inpatient admissions. Navigators are accredited through the Flinders University program of chronic conditions management.
The model proposed by the HCCA is based on the lessons learned from the two case studies, including the staff profile and referral systems. The report’s analysis of the two services also noted the critical importance of IT systems to enable e-referrals and sharing of patient information. Anecdotal evidence in the report suggested that both services were well received by patients.
The report indicates that a successful patient navigation service should provide a single point of contact for individuals where they can receive assistance to navigate across health settings and take a coordinated care approach. This approach aligns with ACT Health’s commitment to providing patient-centred care, which emphasises a commitment that every person with a chronic condition receives the right care in the right place at the right time and with the right team. A patient navigator service will support this commitment and improve the management of chronic conditions.
The report also identifies examples of care coordination being delivered across the ACT, including clinical care coordinators, the geriatric rapid acute care evaluation program, or GRACE, and the chronic care program, CCP. The CCP was highlighted as providing excellent coordination services. This program provides care coordination through a clinical care coordinator. A comprehensive patient-centred assessment is performed. Goal setting interventions are then developed with the patient and the health professionals involved in care.
Next page . . . . Previous page . . . . Speeches . . . . Contents . . . . Debates(HTML) . . . . PDF . . . . Video