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Multi

Disciplinary

Approach

to

Community

Deborah

HARVEY

""

lntroduction

I

am

hoiioured

to

have

been

iiivited

to

talk

todav

en

the

topic of

Mu.tti

Disci.pli.naizt

Al}proa.ch

to

_{Co･tninu'nity}

Can'e,

The

Austra)ian

Healrh

_Care

sysreTn

is

complex and rhis

is

a result of a multi-layered approach lo

funding.

Serx,ic'e

provision

can

be

funded

through

grants

from

the

Commonwealth

Govermnent

of

AustrEdia,

the

various

SLate

C;overninents

or at a corrimunit},

level

by

Local

GovernrrienL

As

a

heatth

professEonal

",orking

in

Communiry

Hcalth

there

is

a need

Lo

be

1'ainiliar

with all

types

of serN,ices Emcl

ttiis

requires a

high

degree

of

knowledge

about

the

serviees avaitable and Ltie etigibiliLy criteria

for

each.

'l'o

ineet

the

needs ef cLients, and

t(}

be

able

to

best

utilise the services

iu

the

field,

IIealtti

Care

Proiessionats

are required to "'ork

in

partuerstiips

alld collaboration ",iLh each other

Lo

ensure

Lhe

best

possibte

oLLtcome

for

the

client.

Toda),

1

will

be

talking

about/

1. The

Aged

Care

Assessment

Service,

the

requireme-ts

of

this

service amd

ho",

thc

multidisciplinnr}, natLtra o[

aged uare ussess]nemt

limks

to scrvicc

dellvary

and

ilive

clierit eutcoincs.

2. The

nature ef n]uttidisciplinary teaTTi",ork

in

other pro

gralns.

3. The

evolving process of

intei'

agemcy partnerships arid

coliaborutkm

for

enhancing a

posiLive

client outcoine and

the

opportunilies

thls

is

presenting

for

hea]th

care ers

in

the

field.

ACAS

Background

The

process

of

Aged

Care

AssessmellL

orlginated

in

Britain,

and

developed

in

rhe

LJS.St

using [an

impatient

:nodeL

The

Australian

sysLeni

is

predoininantly

conimu-*

_tdedi

_tr

_7C[

.).･Ct4

fa

iJ,,i"lwaC:

Sk

).7'n-t **

_Area

_MFL"uger/

_{Ki"sstu[).'Ba.vside}

.Nssessmc'nt

nnd

C[ise

N･Tan;tgeirietitS"uther" IIeulth

Key words:

t-

1

]･

7

V

7, T[',z'

va

'Z-

r7

Y

1

i-

2,_,

el,a;,.IiVlltrE

-r

7

*

Care

nity

based

and

has

a universai national coverage.

The

dex,elopment

process

for

Aged

Care

Assessmellt

in

iXustralia

has

invdved

nalionaE

gox,erninent

policy

ini-t[atives

creared

in

cottaboratien ",ith academic researchers, and a rcgular evaLuation of

perforinarice

and ourcon]es resLLIting

in

colltinuat refineinent of the service svsrem,

Doc'unientation

by

the

Australian

Governmenr

frotn

1975

Ltireugh

Lo

1982

recoillinerLded

that

Aged

Care

Assessinent

should

beeoine

u coinpulsor)' coinponent of

the

national

process

ror

care of

otder

peopte.

In

partic-ular.

to

revie", soine or allapplications

[or

adii]ission

to

nursing

heines,

u inove

prompLed

by

the

sigiiific'nnt

finn]i-ciMl cost of llursiiig

tioine

cnre.

This

",ns iiresult of rhe

intreduction

of

C]ove-irnent

Tiursing

home

benefits

for

iong

term

paLienLs

in

1963,

hoi･vever

",ithouL any ellforced criteria

[or

etigibilit.s,.expendiLure on nursing

hoine

care

increased.

iXt

the

same

time

as

the

desirabi]ltv

of

insti-tutionalisalion

as

the

main

long-term

heallh

care alrer-nariK,e

fer

lhe

frail

elderly

people

"ras

being

quesrionc/d,

In

]'espense

to

these

reconiinendarions,

pilor

prograTns

"'ere establishecl

ill

NSI,Ni

X･'ictoria

and

Tasniallia

in

1984.

Ttiese

pilot

pregrains

Lvere

prirnariLy

Lo

assess otder

peo-pLe

for

reversibte

paLholog},

prior

to

Lheir

adinission

to

Tiursing

home

and

to

estabLish

Lhe

need

for

nursing

hoine

care.

Evaluation

of

these

piLo+'

progrums

iii

1986

result-ed

in

expaiisioT] ar]d refineiiient ol the

prograin

and seine additional responsibilities,

Subsequenr

to

rhe

pilot

pro-gram

ex,aluatien,

Cornmonwealth

Guideliiies

for

AssessmeiiL

Services

were

issued

in

1987

and

thesc

pro-x,ided .a

tramework

for

the

operarlon of assessmenr

teams

in

Australia.

Distribution

of

Aged

Care

Assessment

Services

"/ithin

the

nationat ceiitext

Laid

do",ll

in

Lhe

Coiillnon",eatth

Guidelines.

assesstncnt rea[ns opernte some"rhat

differe-tty

in

each

State

er

TerriLor},.

'I'his

i$

partty

due

to

the

histericaL

deveioprnent

of eaeh

State's

tearns,

but

riiore

importantly,

heallh

provision

in

(2)

MtLlti

Discipiinar},

each

Stare

has

quire

differenr

hea]rh

delivery

sysrems,

In

Australia,

there

are

125

regionatLy

based

niultidis-cil]lillary

A.ved

Care

Assessment

Services

",hich no-, cox,er

Lhe

eiitire continem.

The

Coimneiiw･eHLth

_provides

niost ol

Lhe

direLL

luiidiiig

for

the

Agecl

Care

AssessineTit

Prograin

with additiollaL uontributioiis

from

the

Srarcs,'Tcrritor[es.

The

SLatcs

and

Territories

also

vide the

infrastructurc

and the

breadcr

health

svsLein

within which teams operare.

,AC.SLS's

are

linked

to

othcr

heaith

serx,ices

in

N･tirious

ways,

Tn

somc rcgions

the

ACAS's

may

be

part

of aiid co-localed ",irh coniinuniti' services or coinniLi"itv

henlth

centres, whereas

in

others

thev

inav

be

located

within

acute care

hespita[s,

)L,Iost

teatns

opcraLc

frorn

one

toea-Lion,

ho"'ever,

in

the

largc/r

St:nes

sLtch as

Queensland.

Ltiere are some

reams,

which operau

t'rorri

L",o

or

Lhree

tocEILicms.

In

South

Austi'alia.

the i'Xged

Care

AsscssrnenL

Services

were

dex,eloped

-'ithin rhe organisationaF

struc-ture

of

the

Doniiciliary

Care

Service

SvsteTn,

",hich ",as

pre-cxisLing,

and

previded

ho]ne

assisrancc and

hoine

based

rehabMkition services.

Tn

the

Northern

Tcrrjtorv,

tlic

ACAS's

provide

a service

to

both

the

ag'ed and

],ounger

people

",ith

dis'ibilities,

Thcre

arc･ unique

denio-graphic

ai]d social

factors,

ivhich

influence

thc,

scrviee requireinenLs aiid uv'iilnbiliry of

the

scrvice

in

Lhe

Northern

'1'crriLor},.

The

Kingsten

iK'XS

is

locatcd

at

both

of

irs

sites ",ithin

Coinmunity

Health

Centres.

Funding

of

ACAS

Coniinon"･e

itth

funding

"ras

progressjN,c'

ty

rllade

uvail-abte, which alLo",ed rhe niajorit}' of reg'ions

in

euch

Stnte

c)[

.4usLralia

to establish

.'Xgc/d

Clare

iXsscssniLnL

Services.

FiJnding

is

generally

calculated on a

formu]a

that telaLes

rhc

dollars

.'dtocated

to

the

proportion

()f

peop]e

in

thaL

particuiar

.'XC.qS's

cEdchineTit area over rhe age ot'

eiO

1'ears.

['ec)ple

in

special needs

groups

such as tcains

in

ren]ote and rural areas atLraut addiTional

funds,

In

iriy nrea of

Baysidc

N,Icabourne

there

is

nn

ACiXS

budget

ol

Sl

l,300.000

ro run rhe servicc.

This

covers all

items

of

budgc'Led

expellditLire.

The

Ieam

has

two

ollices

niid aTi efr of

16 i'ull

tirrie

equiv'LleTit st'iff.

ACAS

Objectives

The

('ore ebjectis,6

1'c)r

uii

Aged

Care

iXssessinc'nt

Service

is

To

co]nprehensivel.v asscs:,

Lhe

"eeds of

t'rail

older

_peopLe

and

facilitate

access

to

av'iilable carc' ser-vices appropriate to

their

needs.

']'his

corc objective

is

supported

by

a nLiinber of

principles/

'

Equit}

of aceess to all

grotLps

livirLg

i-

the

coni[nunit).

'

Preventlon

of

preiriiii'urE'

or

inappropriate

ad[nissien to

,'Xpproach

to

CommLmitv

Carc

l23

residentiat care

faciLities

'

(llic/nl

and carer

involvcniLiit

'

Faeititation

of access

tt)

a combinalion ot'serviceh te

meet

_peepLes

needs

'

Asscssimerit

is

coniprehensive and enconipasses

the

resleraLive,

_physicul.

ineclieai,

_{psycho[ogical,}

cultural and

social

diinc/nsions

et'care needs.

Definition

of

an

ACAS

Assessment

The

definirion

of an assessinent

describes

ttie

process

of acquiring

informatlon

abc)ut a

persoiL

",hich can

be

used

to

develop

a

plan

for

future

inLerN,eiition

or

future

ccare,

This

assessnient

process

can

be

initiuted

by

anyone-the

c]ient,

the

clienr's

farniiv

or

1'riencl,

Lhe

toeal

lliedica]

practirioner.

rhe

hospital

doctor.

a ceniinunity ivorker. the

police

f)r a concerned

pcrson

who

is

_quite

uninvolved

"'ith

the

individual,

CJowwne'nceni.eiit

Qf.!Lssagg7?'t.en.t:

ACAS

teains operate a

single

point

of entry

inro

rhe assesstTicnt

process.

At

this

point

all referrals are scT'eened and appropri'iTe

irifor-inatiori

is

collected and collatcd

to

obLain u

Loillprehen-sive

hisrory

ef lhe reason

for

rcl'c'rrat.

An

AC.ALS

nssess-]nenr

is

nor an a]ternativc･ to

Priniarv

X,iedicnl

_Care

so

therefore

there

needs to

be

a cooperative ",orking

reia-tior]ship

",ith carers,'ddvocates and oLhers

illx,olved

in

n

persons

care and support

to

ensure

thaL

trail

eider

peo-ple

gain

ttie

iull

beiic/fit

ot' a

holistic

assesstnent.

This

is

a cotiaboruLive

_process

bel'-'ec/n

the

rcferra[

source, the c]ient,

the

tocai

niedicaL officer and

the

Intakc

",erker,

The

Tntake

_phase

is

seeii iLs the ceTnmenccincnt of an asscsstnent and as inuc'h

_pertinent

inforrriation

as

possible

is

obtained

to

f.'tci[iLate

the n]located assessor

In

under r'lking a

face

Lo

iaLL

ussessirLent.

Atso,

there

is

consultation ",ith assessment staff about

the referral request and

the

referral

is

aglecated

to

an

appropriaTe

disciptinc

"ithin

the

team

dependent

on the

llature of the referral.

I'zt'izpose

qf

an

..IC:4

7'

As,s'ess}ne'rtt-C;i.icnts

aw.d

F}].in

ities:

iXn assessment of ani older

_person

cati

be

x,ie",ed as a

decision

making

tooL

Ttie

assessment

is

a

proccss

of

col-ktt'ing

inforTnation,

idc'ntiLving

the

c]ient's -'ishes and

developing

an outcorne

_ptaii.

Although

initially

introdLLced

in

,Dtusrralia

to

monitor

Lhe

approprlareness of nursing

tiorrie

adniission,

the

pLLrposes

of an nssessnient

have

bc'cJi

expunded ",ith r('finemenL oi

the

service system,

The

purpose

ol'an iissessment can

he

t,ie",ed

d]iTcr-ently

by

ttie client, the service

provider

and the

_poticy

inaker,

likewise

the

inl'ordnaLiuii

obtained

froni

an

assess-inent can

be

used

iii

a variety of

different

",ays

(3)

I24

ee

'"

as

i.t.-

t/if,

goal

is

likely

to

be.

1"

Australia,

Lhe

assessment

is

ec]

to

be

c]ient orientaLed and

bc

responsive

to

the

clienr's

needs, ns "･ell as

fulfMing

the

requiremc/nts of

rhe

vice

providers

and

Governnient.

The

exLenL

to

which this

happens

will vary

between

teai]is and

individual

clients.

FroTn

the

client's

poinl

of

vie",, a

thorougti

ex,atuation of

their

medical,

physica],

Eunct[onal,

psychologic'al,

sociat and environincntal needs

are expected.

In

addition, attention

to

the

carers needs

is

iinporLant.

Subsequently,

the

provision

of

inforination

and advice on

the

choices ax,cai[able

to

the

cLieitt

is

gix,e'n

based

on

their

particular

clrcunistances,

p]'obtenis

nnd strengths.

Information

regarding resideirtlal care

is

only one of

Lhe

potcntial

choices.

Advi['e

regarding

irriprovcd

ical

rrearnient,

rehabilitatioii, respite, coinniLLnity serx,ices,

alds and app]iances, a"d

guidancc

regarding

the

benefirs

and ax,a[labilitv of ench

is

desirable.

The

process

of assessment

is

a model of

therapist,

client and

familv

collaboratio"

t'o

reHch a

defined

clusion ",hich

is

underpinned

by

a

problern

s()ti,ing

approach.

At

this most

fundamental

level

the

assessor

is

working as

part

of a unir of

partic'ip:tnts

in

a

process

Lhat

is

multi

disciplinary

with

the

faniily

unit

bcing

at

the

cc)re of

the

rriodel.

ACAS

Links

to

Legislation

The

proeess

or

ACAS

assessments

is

guided

by

Commonwealth

legislation

in

the

1'orm

of

the

.4ged

(]ao'e

Act

o.f

1997.

This

act sets out

the

details

of eligibility

and approx,iil oi a

person

as a care recipient

in

a

Coinrrion",ealLh

I"unded

facilily

or

program.

1'he

acL einpo",ers [he

Secrelary

of

the

Cornnioll",ealLh

Departmei}t

of

11ealth

and

Aging

ro

approve eligibility

for

residential care.

'L'hls

in

turn

is

delegated

do"'n

Lo

specific members of an

iXCAS

?md

the

Leam

membcr

with this aulhority

is

referred

to

as a "dctegate",

_The

rote of a

delegate

is

a serious one wlth certain

lions artached

te

its

staLus. iX

delegate

must

be

a

son who

is

one of

the

core

disciplines

within

the

ACAS.

nnd

the

delegaLe

must a[so comply with all applicablc

Conllnen",ea[th,

State

and

Territor},

la",s.

Not

all tcam members

ht",e

delegaLion

status and

in

{/ompletiiig

the

Commonweatth

Approvals

Fo]m

lhe

assessor must

be

a

differenL

person

lo

the

delegate.

This

requires the

delegate

aiid

the

assessor

to

consult

and agree oii a ctient's

level

of care 2md

the

mended oLtlcomes.

This

c:omponent

is

crucial

to

ensure

accountabi]ity of lha

process

and

is

_part

of

the

_process

o ±

'

inLerdisciplinary

consuttation.

Delegatiori

o[ auLhority

for

approval of

NLirsing

Home

and

Hostel

admission

is

dilj

30 _k

_ng

3 }-u

at a

poinl

today

whcreby i'XCAS

teatns

havc

assessed

everyonc entering residential care

in

iXusLralla.

ACAS

Team

Composition

The

cornpositioti of an

ACAS

Emd

the

experience of

the st'iff

is

vital

iii

deterininiiig

tearn

effeutix,eness.

IdenLLy

rhe reaTn should cornprise of inein]]ers ",ho

have

slve experience

in

zhe

fie[d

of conimunity-aged care and

a

broad

knowledge

of residemtiai anc] communiry

vjces,

iXn

ACAS

must comprise of or

hax,e

access ro n

range of

disciplines,

skills iind expertise

iii

order to rnake

an aceurate and ceTnptete assessmeiit.

The

ide'il

sition shou[d

include

Nurses,

Gerintricians,

pisTs,

Occupational

rherapisrs and

Secial

workers.

Acuess

to

more specialist serx,ice such ns

Neuro

psychologists

should

be

available on a iieeds

basis.

Everv

meinber of

Lhe

.ALCAS

t'unctions

",Ithin the

model of a Tiiulti

disciplinary

Leani,

however

-,hen

they

are undertaking a

t'ace

to

lace

assessinenL

they

are ol'tcn

doing

this

in

rhe capacity of an

iiiclependenL

er.

It

is

unusual

for

two

members of ii teaill to x,isit a

c[ient

joinTly.

and oftem

the

cLieni "'iLL oiily see the one

assessor

for

that

episede of cnre.

The

multi

disciplinary

nature of the teain

is

enced wheii the

_process

of teani consultation and

uiission occurs.

This

can

be

at

the

cornnienccniemt of the

assessment

process

",irh

the

Tnrake

officer oT'at a

lnter

s"ge through the

_process

of case conference.

Assessment

Process

'I'here

are a nLLmber of core actiK,ities thnt are critical

to

thc

.DLCAS

comprehensive nssessmellt

_process/

'

Initial

cliemt assessnient and naeds

identification

As

previousLy

statcc] thc/

InEaka

_process

is

the

ning

_phase

of n corriprehensix,e assesstnent, zhls

is

lowed

by

a

face

to

face

assessment at the cliemt's

ciple residence.

Sorrie

assessineiits are condttctad

in

pital

but

inost are Lmdert Lkc/n

in

the cLient's

home.

The

assessirieTit ex'Linines the person's sociai,

ronmie-tal, incdicnl fLnd

[Linctionai

capacity taking

into

acceutit "'here thes,

Live

and "'ho zhey

iix,e

",ith,

The

nssessnient

ls

the

first

step

in

a ulietit cun[rcci

prc}blein

solving approach und

is

cotiduclc/d "ith client!faniiLy

pnrLiciputlon.

'I)ex,eiopr"c/n[

oi' ,a

Care

1]lan

Follo"'ing

the collection of assessnient

inforniaziai

the xssessor

discusses

the

issues

idc'mtific/d

"'iLh

the

ctient/fam"y a]id nl This

point

a

plan

ef care i'ectuired

Lo

ineet

des[red

outc'omes ol'

the

cLiant as weLl as ,'XCAS

idclltific/d

areas ot need are explored and addressui.

(4)

N･IL]lti

DisriplimLr),

iXpproach

place

ofr{/sidence.

Agr[

"nenl

is

rcachefl ovc/rwhnr Typa

of assistnrice

is

1'o

be

ai'ra-ged und

fu]1

client cerise]it

is

sought to

disseniinate

any pertinent

infortnation.

'

Arrangimg

rhe

Care

Plan

to the poiTLtof eft'ectlve

ral

Fotlo",ing

the visit and care ptanning session lhc･ ctient's case inay

be

presented to /.L

C/ase

Cont'erence

for

a team approach zo

_probtem

sotvrng and vatidation.

Rcferrals

are

i-itiuted

lo the

identified

service

_providers

arid ussessiTiemt

i-forrnation

is

att/,iehed

to

Ehe referral.

.

Emsurimg

Cai'e

P[an

lniplenientatiun

Once

areferra[

has

1]een

niade to another serx,ice

lh(

ACAS

roLe

En

preparinl.T

lor

servica

delivar.v

is

conipk/lc/.

N'lany

servlces notiLv

the

iXCiXS

assessor whcn ;Lclieni

coniniences on a service and

this

iiTlorinarioii

is

added

to

the

cliem's recc)rd ?'Lscwiden[/c' of care pLaTi

nien[ation.

The

onlv meanH lhal

Assussnient

staff

have

of

the

eiiecLivc'.nc/ss of Lh{' cure L)]a-the:' established

",ith a ciient

is

-,hen

ihc

cliemt rccoiitacts rhc'

ACAS

for

H

t'urther

assessinent.

iSi

hi[e

rhis ]nax, cause a

Tack

of sr'Lff satisfnction

in

terins

of ev'ilualion of a care

plan

uiTd the outcorne,

ir

uecessitares a

high

[exet

ol'

inLer

ageiiuy

iuterdisciplinary

collaboration so

that

aEleventuMlities, nre Tnanaged

effec-tively,

Case

Conferencing

and

the

Multi

disciplinary

Approach

)･Iutti-disciplinary

assessnienL

is

a(thleved

through

the

process

ef

Case

ConfereT'bcing,

joinL

assessnienLs,

Eollo"'

up visits, cross referra]

to

ethcr se"iees and Ttie

dele-gatlo-

proc'ess.

Ali

coniplex c:tses are revie",cd under

Lhis

tearn

process

which

iii

_part

is

an :lcceulltlbitit.x' IIIt'chEiilisili

-,hile at

thc

sanie tiine

_provides

a

forL"n

[br

cottegiaLe

learning

and

group

decision

Tnaking,,

C;ase

Confcrence

is

attended

by

ACAS

staff as well as

Visatitig

Nursiiis,

Servicc

stafL sLaff

froTn

the

pss,chogeriatric

assessiiLeiiT'

servicc,

thc'

teain

Geriatrician

and olher agencies as ]'equested.

'rhis

offers a

broad

base

ol'

health

_{professionals}

all con-tributing

in

Lhe

disc/ussion

relating

Lo

_parLicular

client

cages,

XCany

clienLs assessed

bv

the

iXC

'XS

are also

cur-rent

clients

of thc agencies attenc]ing case cc)nl'c･rence.

There

is

aiso capacit},

lor

n colli-iborative approacti

Lo

care

ptanning

"･ith

local

doctors

Through

the

(:ommonwealth

)L,Iedical

Rebarc

Schcrne-)L4edicnre.

Local

Dectors

c''inclaini

through

tt,ledicare

for

participation

in

care

_planning

for

a client "'ith orhc･r serx,ice

providers.

']'his

_is

parL

of an enhanccd

_pri[nar3,

cEire schenie

esrab-lished

over

thc

past

L"'o yenrs and -,hich

is

sLill

iii

the

lo

(oinrnLLnilv

Care

125

early stnges of

deve[oprrient.

Outcome

of

Asses$ment-Referrals

to

other

Agencies

Aged

Care

AssessmeiTt

Servives

provic]e

an

inrerface

bet"'een

aged v'Lre servic/es, ceTnniuniry and

Health

Care

serx,ives aiicl

have

:-i"

i]]']portnnr

role

Io

_play

in

devetop-ing

llet",orks

])enveen

_general

_{prac/ririoners,}

clients and

oLher serNiue

_proi,iders.

Ttie

n]nintenanc/e ef

thesc

links

and rel'erral ineuhanisins nre extreTneiy

important

as

rhc.x,

assist

i]i

the

timely

provision

of sLLpport to

people

requir-iiig

ceTnmunity services and a[so

facMtaLc'

access

L'roin

communitv services to

th(t

usscssincnL service.

Types

of services conirnodi]}, refL'rred Lo or referrals

receix,cd

from

are/

'

Local

C;ux･

ernnient stll'i,icE/s such

'Ls

N,T{

i]s osi

SS/

heels.

Doinestic

assistance,

_persunal

c/arc.

in

]iomc

respite care.

'

Hoine

and

Con]rnurbiTy

C

ibre

Services/

these

are

grams, which are

.ioin(1>.,

1'Lincic/ci

I}y

the

Commonwealth

and

State

C;overninenls

and

includE'

Day

Centres,

Doniiciliary

.Itiied

HcalTh

Scrv[c'us,

a-d

Hoine

Nursing

Services.

'

Cornmunity

HeaLth

Centres/

ih{'.sc/

_provide

Cc'iitre

Based

assistance

in

the areas of alLic/d

hc'fblih,

commLmity

ing,

and counselling ;'tnd elhur spccialist services.

'

C/ase

"･lanagenic,nt

sei'vices ",here

there

is

inonev

abte to

purchtLse

sc･.rviccs to enhaiw{,

the

care

p]an

and

to allow

taiLoring

of'

tlic･

c''Lrc'

plnri

to cLie-r need.

'

Communrtv

RehabMntEon

Serviccs/

lliesu

can

be

either

Ceiiu'e

based

or coinTnunit},

bascd

prograr"s

vL'here

there

is

a

treating

tean'iof

ther,apisls

xs

ho

lubvc/

ib

bilitation

focus.

'

Resiclei]tiai

Care

Services-such

us

Hosteis

and

Nursirig

IIoimes

'

iXc/Lite

n]id

Sub

Acute

seutors of the

Hospil'Ll

ptc,lwerks.

'I'he

provlsion

of

inlbrtn.ation

and assessn]ent

details

to another serN･ice so that

Lhey

caii approprintely

co-ordi-nate rhe care

plan

ironi

Ltieir servic'e

is

a critical

ele-Tnent,

This

process

rcquircs Lrust and collaboration ",ith ether

therapists

in

thc'

field

and often st'kff"'ill

be

liais-ing

Lvith the]'apists

froTn

another

discipEine

te

dissenii-natc

the

inlorinaLiou

required

to

facilitarc

an opti[nai

client outcotne.

Interesting

Data-Australia

wide

Ail

iXCi'XS

services are required to collect a

Narional

N,]inhnuin

_Data

_SeL

and

L'his

requirenienl

is

a condltion

of

Grant

betiveen

the

Cotnnion",c･alLLi

alld

S[ate'

'I'{/rritory

_{Gox,ernrller]ts.}

_[[he

_data

_is

collect{".d

bt,

each

.Kssessinent

Service

and sTTbmitrcd

quarterly

to an

(5)

126 J'e.\,fiV:!i;,

iXCAS serx,ices with

daL:t

for

policy

and

_program

dcvcl-opmcnt, strategic

planniTig

nnd

_perlerniance

inoniLoring.

ficpo}'ti.･ng

perind

from

･hity

1999Vu.ne

kPOeO

'

Tn

the

reperting

period

[roin

Jui},

1999-June

2000

183.584

assessnients ",ere itndertaken

b},

iXCAS

services nation

wide.

Thls

represented a

2.5C.t･i]

increase

from

the

ous vear.

Of

these

asscsyrients

48.5Ce･i]

were

mended

for

eommumity

livi-g

and ,13..Y]i, _were mended

for

residential cure,

'

The

mosr coinmon

diagnosis

wns

Dcmentia,

followed

cLosel},

by

Arthritis,

Stroke

and

Heurt

Dis{/age.

Many

clicms would often

have

multiple

diagnoses.

'

The

inajor reason given

for

refe]']'ai ",as

for

u general EIStsebblTl(/nt.

'

St'itistic/nLly

Lhe

largest

group of clients assessecl "c rc/

in

the

80-84

_3,ear

otd age

_gi'oup,

'

OveralL

there

has

been

a shift to",ards a

higher

ber

of coininunitv

based

recer"rnendatlons.

1'his

has

been

attributed

to

the

increased

;bv'LilabiLlti･of

nily services that support

people

ut

hoinc

and their ers.

Examples

of

Other

Models

of

Multi

Disciplinary

Approaches

to

Community

Care-Service

Provision

Home

Based

AUi.ed

Heat.th

Seitvice:

The

Ilome

Based

Attied

Hcalth

Service

is

n

doilliciliary

tcatn of

profes-sienals who service clients who

for

reasons of

frailtv

or

disabilitx,

are unable

to

[enve

the

hoine

to

attend cenrrc

based

services,

This

team uovers

3 Locai

Gox,ernmenr

areas and

has

an

{)ccuputional

'I'herapist,

Physiotherapisr.

L)iet[cian,

Speech

PathoLogist.

Podiatrisr,

Con]inunity

11eat[h

Nurse

and aTi

Allied

lleulth

i]Lssistant.

Clienrs

of

this

servicc are often

treated

bv

niore

than

one

disci-pline

and sraff rcview cases

fortlligtnl},

at a

formal

level

but

in[orniatty

this

can occur <)n a

daily

basis.

[['he

team

is

[ocated

together

as a unit ",hich enhances

their capacity to

inLe.Trate

and share

kno",ledge,

boLh

about clients

but

also abour

professio"at

uhanges and chaLlenges.

The

level

of support

these

",orkers

give

to

each other

is

very

high,

which

is

strength of

the

pro-grarri

and also a[lo"'s

for

joint

visits and collaboration

ivitti soine of

the

Tnore challellging

issucs

that

they

c'in

faee.

Thc,

use of an eleetroniu clienL

file

nianagenient

sys-tem

throughout

this

services enables

integration

oi'clienr notes and changes that alL sLal[

have

ac/cess to, this

enhances the multi

discip[inary

nature of

thc

sers,ice,

']'he

type of client often seen

by

rhis service "iou]d

1)e

a onc who

is

over

the

age of

80 years

;ind ",ho

is

expe-riencing niobility

_probleins

",hich reqLiire the

interveii-a:30

kag

3

L'J-r[on of a

Physiotherapist

for

_gait

rex,i'ew, and

Occupationat

Therapist

for

review of

hotnc

sal'ety and

equipment

provision,

This

person

rriay also require

l'odiatry

as

they

can no

longer

cut

their

own

tocnai[s

and

rheir

feet

mav

be

in

such a condirion

that

this

is

contriburing

ro

mobility

issues,

ildditionally,

this

clienr may also

have

continence

issues

which require

the

Comrnunitx,

Nurse

to

become

inK,olved

and as well

the

Carer

may rcquire some additional support re

the

home

situaLion which

thc

nurse

rhrough

counsel[Ing, would

underLake.

Ttie

issue

tor

clicnts

in

this catcgory

is

often one of

Lo",

bod},

weight and at

this

point

the

dietician

may

bec'oine

inveived

and

if

thc'

ctient

has

s",allowing

issues

then

the

speech

paLhoiogist

and thc

dlctician

would work together

to

incet the clients nLilritional needs

effective-ty.

'Vhis

tcam

has

a

true

multidisciplinary

fraine"'ork

whicli ",orks ",ell

for

the

client ",ho wishes

to

reinain

living

ar

home

and wants

to

be

as

independenL

as

sible.

Convm.unity

Rehabii'i.tation

Ceittre'si

Cc)ininuniLy

Rehabititation

Centres

provide

a servic'e

th'it

has

a

niul-Lidisciptinar.x'

focus

and

proinotes

time

liniited,

targeted rehabilitntion ro achieve and retain optiinal

functionat

indepcndc/nce

of the client.

The

inajority ol'

CRC

clicnts

are adu]ts

living

ii]

the

coininunity

for

whotn

rhere

are

clearly

ideiitMabLe

rehabllitatlon

goals,

Core

servic/es

pre-vided

by

n

CJRC

are

Rehabilitation

medic[ne and or

geri-atric mediuiiie, nursing, occupatienal

therapy,

physio-therapy, social ",ork and speech

pathology.

Aiiy

or aLtof

thcse

disciplines

nu]y

be

invoLN,ed

hi

Lhe

cLient's

initial

assessTnenr and c'Lre

pla-nillg,

and each

disciptillc

is

fu[11,

involved

",ith oiigoinst revie", of

thc

uare

pian

and

d[scharge

planning.

Ttie

inost coninioi] niodel

fer

CRC]'s

is

a co-Location or

integraLion

arrangen]ent ",ith a

hospitaL

l･Vithin

Southern

Health

thc

model

is

different

with

CRC's

being

co-locat-ed or

integrated

",ith coininuuity

hea]th

centres or

day

centres.

The

advantagc of rhis

is

a c/omTnuiiity

focus

with

the

einphasis

being

on cc)]nmunity

inLegration.

.,Xlso,

rhis

rnodcl cnhances

the

epportuiiit},

fer

a

hea[th

proniotien

and

"wellness"

apprc)ach and

gives

potential

for

impreved

sLafl' supporr,

Due

to

the

toininunity

locarions

of

the

CRe's

there

are ]iiany opporrunities

for

staff

to

",ork across organi-satioriaL

beundaries

vvlrh other

therapists

boLb

at a

ser-vicc

deliK,ery

Ievel

aiid aLso

in

thc area of service

pltm-Ilillg.

Rehabititatio're

i'rt

t.he

iloine

Prog7'a7n/

The

Rehabilitation

in

the

Hoine

Pregratn

prox,ides

elder

people

Lvith a choice

(6)

N'lulti

Discipllnary

i

I'eople

"'ho usuall)'

go

onto this

progrnrn

are niedicall.x'

stable, aTid -,ere

independent

prior

to

the episode of

ill

hea]rh

and require

tess

ceinplex rehabilitation.

'I'he

pro-grain

ainis to

be

c[ient

focused

with

the

desired

outcorric

lor

ttie cticnt

bcing

the

provision

of a

personaliscd

ser-vice

that

encourages

indcpendence

and restores con[i-c]ence

in

their abiliLy

Lo

inanage aT

hoTne.

This

prograin

also aims

to

offer a

high

qua[ity

respon-sive serx,ice

LhaL

is

flex[ble

ro

mc,er changiTig iieeds.

CIie"ts

are aecepted onto

thc

program

after

being

assessed

by

a

geriatrician

as rcquiring rehabilitation.

Case

inanageincnt and a multidisciplinary npproach Mre

criLical

to

this

prograins

success, iX care

plan

is

deveL

oped

in

conjunction "rilh

the

clieni･, their

farnily.

case tnanager and serx,ice

providers.

This

is

formalised

by

a written and signecl serx,ice

agrcetnent

prior

ro

the

commencement of

the

prograin

and

the

discharge

plan

is

revie",ed on a ",eekly

basis

b},

thc

treating

team

and case mannger.

C:ase

Managemenr

is

a system rhal

is

used ro achieve

desired

cticnt outcoines

b},

provlding

a well co-ordinated expe-rience

for

clienrs and

faTni]ies

by

synchroiiising care activities of multiple

discipliiies

and

providers.

It

is

based

on

building

reiationships and

dcvejoping

nct",orks and

is

episode

l'ocused.

Tb,c

case management

in('tudes

the

following

acLivities/

'

Negotiatioti,

co-ordillation and the arranging of services.

'

Interventgon

at

key

pornts

of

the

care

ptan

as required

'

Addressing

and resolving client care

issues

Underpinning

this

is

ihe usc ol'[-L

problem

solving

approach,

Care

is

provided

from

the

program's

allied

henlth

therapist's

xvho

provide

all

treatinents

for

the

ulients on

the

progrnm.

This

cHn

inchtde

daily

physio-tilerapy

and occupational therapy

(if

required), other ser-vices c,

g.

personat

care and meats are

provided

by

eut-side services under a

brokerage

of serx,ice modet.

Ttie

typicat client

[or

this

prograin

is

able

to

transfer

"'ith tlie assistaiice of one

person

ar]d also oiily requires ene

person

to mobilise safely.

The

ideaL

client sheutd also

be

able

Lo

Leave

the

home

with

the

aid of aiiother

per-son

in

case of an emcrgc･ncy and tnust also

be

able

to

participate

iii

personal

care "'ith ase/istanc/e.

Peep]e

",ho

do

noL rneeL ttiese criteria -,ould

be

offered

illpatiellt

rehabilitarion,

This

program

relies

heavily

on

the

mullidiscip[Inar}, iiature of

the

te'un

and

this

is

forrnalised

in

t]weeklv

case review and

discharge

ptanningr

session where att

staff

_participate.

This

program

has

the

capaciLy

Lo

inanage t"･ent}, eight clieitis a[ any

given

point

in

tiine and

is

p.arr

of

the

Rehabttir'ition

and

Aged

Services

I'rogratn

at the

Xppreach

te

Cenirnunitv

Cure

l27

Kingston

Centre,

X,Ie]beurne.

Future

Directions-Primary

Care

Partnerships

The

State

Goi,ernnient

of

V'ictoria

has

over

the

past

two

years

has

coTnmc/nced a

precess

Lo

revie",

the

niod-els of service s],srenis

in

place

hi

erder

to

facilitate

bet-Ler

access and care outcomes

for

clients,

This

has

result-ed

in

the

forination

of

I'rimary

Care

Partnerships,

which

are attiances of rcgional

Communiry

Health

Services.

The

aiin of these

_{partllc･rships}

is

to

improve

practises

within ttiecurrent assessinent

process.

as weH as

improv-ing

entry to

Lhe

service system and needs

identMcation

for

the

consurner of

health

services.

As

part

of

thc

parT-nership the

issues

()f

Service

Co-ordlnation

and

Service

l'lanning

are criticaL

Parrnerships

have

developed

ConiinuniLy

IIealth

I'lans

that rcflecr

how

the changes

required

in

Lhe

service systern ",itloccur.

There

are a nuinber o[

ke},

principles

which are

dri-vi"g

this

process,

tlte

key

enes

being/

'

Reduction

in

unnecessar},,

duplicate

or

intrusive

maiion collection.

'

Consumer

needs are addressed

b],

a multi

discipljnary

approach where appropriate.

'

Prozeetion

of

the

eonfidentiatitv of consumer

tion and consumer consent to

information

sharing.

'

Einpo"rernien[

of the collsunier

in

heatth

care.

'

iX

flexible

probtem

solL,ing approach

is

used

by

health

care

practitioners.

'

Assessment

practise

is

guided

by

the

practitioner's

icai

amcl

professiona]

expertise and

is

undertuken

by

staff

that are appropriateLy

trained

and

qualified.

Tn

achieving a

better

access

to

services

for

consumers the

partnerships

have

had

to

involve

a

broad

range of service

providers

in

the

development

of a new model.

Local

doctors

are also

invelved

in

this

process

and

there

is

a sLrollg collllllitmellt t'ocmlSuMer

PEirtiCiP[ltion.

In

erder

for

nny ne-, inode] of service

provision

as

there

is

strong recognition thtn

including

consu[ners tis

fu]1

partners

in

lheir care

iniproves

health

and care outcoTnes,

iSiithin

the

Kingston.Bayside

Primary

Care

Partnership

there

has

been

a consultative

_process

to

dei,elop

Common

Standards

of

I'ractise

whicti ttnderpin

the use of (/ommon

tools

for

Initiai

{/ontact and

initial

needs

identiEication

as "'ellas care

ptanning

;ind care co-ordination.

All

services wi[l

be

using

i/hese

standards of

practise

and

thcy

should result

in

c[ear and

irnproved

relutionstiips

between

serx,iees which should ultiinately

benefit

thu

consurner.

As

well these standards should encoura.ve services nnd

service

providers

to review anci appraise

best

practise

and ",ill aet as Ei

guide

to assist atl

_participants

",hen

(7)

I28

-.

i7

_1ti

_it

there

is

aiiy

doubt

re what steps

to

follow

or

if

there

is

any

disagreernent

of opinion.

Underpinnlng

the

standards

is

the

e]ement of

trusr

belween

serN,ice

prox,iders

and a

commitment to work eollaboratively togcther.

Some

of

the

Standards

that

have

been

worked on and

agreed ro are as

follows/

'

Duty

of

Care

and

Ctient

privacy and confidenllaliti,

'

Tiinely

response and

Capacity

to receix･e relarrals

'

Accurate

and comptete referrai

information.

'

Health

Education

It

is

at

Lhe

care coordination,'care

_plEmiiig

stage

that

the

need

ror

a mutti

disciptinary

appreach

is

best

seen.

At

this

point

serviee ceordinatioii

plnns

are

to

be

oped

for

censurriers wtio need iiiultipLe agencies

to

port

them,

who

h:we

complex unre needs and whose

come wi]]

be

better

if

the

care nnd services

they

require

are eo-ordinated across agencies ever a specified

period

of

time.

Henlth

Care

Professionals

will

be

expected

te

work

across

professionat

and organisaLional

boundaries

to

meet

the

ideiitified

needs ef the clienL, and ttierevie". of

the

effectiveness ot

the

care

ptan

wilt also

be

at a multi

ciplinary

leve].

This

process

is

stillvery much

in

the

develepmental

phase

and

is

requiring staff

froni

many

differing

disciptines

te

think

nbout

how

the

new system

might

be

structured.

The

process

of

_plallning

for

service co-ordillation at

this

level

has

resuLted

in

H

_great

cleal

of reflect.ion on

ho",

our systein currelltly operutes a"d

how

"'e can

work

better

together

as

_parL

ef a more expansiN,e

tearti

of

henlth

care

pro[essionals.

Along

with changes to

thc

way services are

nated

Lhe

I'rimary

Care

Partnership

also offers exciting

opportuniLies at many

Lcve[s

for

new

devclopments

and

initiatives.

These

can

be

rcEatcd

to

Health

I'roinotlon,

Mental

Health,

Younger

i'ec)ple,

Chiidrcn

and more.

One

excitillg

initiative

1

wish

to

mention

today

is

thc

Falts

prex,entien

eollaboratix,e:

KingstonfBayside

Falls

Prevention

Collaboration

This

colLaboration

involves

a

group

of community

organisations working with clients who :ire at risk of

[alling

or who

have

aLready

fallen.

Partner

agencies

iti

this collaborat'ton

include

a range

of cotnmLenity service

providers,

GPs

and

Gonsumers.

This

projecL

ainis

to

iinplement

a

targcted

focuscd

intervention

that

",oLiLd

develop,

trial

and

rnote a cotnrnunity

based

model of

falls

and

fall:s

injury

preveiitio"

for

t'rail,

aged

pceple

living

in

rhc

t},

in

the

Kingston,"Bayside

I'riinary

Care

I'nrtnership

ciltchlllellt.

eg30tsng:3t

The

objectives of

the

_program

are/

],

To

dex,elop

and

imptement

a 'whole

o[ system' approach

that

systematicatiy

identib'es

frail

and aged

persons

who

hui,e

fatten

or are at risk ef

fails

lnjury

iri

lhe

Kingston

Bavside

PCP.

2. To

improve

the

assessment ol

falls

risk

fer

frait

and

aged

persons

who

have

fallen

or are ut risk of

fatls

injury.

3. To

irriprove

the co-ordination c)f serviccs

for

frail

and

aged

persons

who

have

fallen

or are at risk of

fails

i]ljury.

4. To

proi,ide

specific services

for

frail

and aged

persons

who

have

fatlen

or are at risk of

falls

itijury,

There

is

a

bilateral

agreement

between

the

Centra]

Bayside

Dix,ision

of

Generat

Practice

aiid

Parkdale

CRC

For

the

duration

of

Lhe

I"alls

Collaboration

Project.

This

agrcement outlines

the

requirements and

bellefits

of

rlcipation

in

the

Falls

Prevention

Collaboratioll.

This

a[so

inx,olx,cs,

support and training

for

staf[

in

the

fie]d

of

falls

prevenzion,

along with the

dex,eioprnent

and

implemenlation

of risk screening

tools

lo evaluate lhe

risk of

falling

for

older

peopLe

entering

into

the

service

system,

Conclusion

Tn

conclusion

there

are manv

levels

where

bv

a

health

care

_professional

can work

in

a

framework

of

cip]inary co-operation.

･

On

a

_professiona]

Level,

Lhe

multi

discipLinary

tc/ain

approach

is

an effective medel to support

decision

ing

and to vatidate choices made with the ctient that

lead

to an effective care plan.

'.At

a

fundamental

Leve]

lhe therapist werks with the client and

family

to ensure a positive care eutcome.

This

tevet

of cotaaboration

is

essentiat

in

any therapeutie

tionship

but

is

of

_parlicular

iniportance

in

the

nity.

N'S･'ithout

this

any care

plan

established will at

best

be

umsutisfactory and at worst ",ili t'ail,

'

At

a service ss,stem

Ievel

there

is

also great capacity

at the present time te partlcipate

in

a ramge of

tives

with ether service

providers

and

Health

Care

I'roiessionais

in

order

to

move

forwards

in

a new model

of

lntegrated

co-ordinated care

proN,ision.

Bibliography

1}

Commonwc･aLth

Dc'partmc'nr ot' IIealth :ind

.lged

C]are.199Y.A,qed

Ca.t'e

Assesstftettt

c['rt(t

Approttat

Guidet'irees.

2)

Coninion",caith

Dc'parrnienr ofIIeHlth:ind

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(]are.2000.A,qed C"t'eAssessllterltIi}'ouram,

q}ei'atienttt

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jb)'

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KingsL{)TL'Buyside

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Carc･

Partncrship.

2Ue2.

Sei'ttice

Coot'(tinat'ion

Protocot

,･lfanztat.

10)

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{)bre

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LtO02.

Fboth,oldon Soj}'tyF}'Qief't.

11)

Kingsrfm

iXgc'd

C/}n'e

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Auect

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eo.oa

13)

Parkda]e

Commun[ty'

Rchabj[itat[on

Sei'vice.

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Serl,ic'eProt,ido}/s.

14)

Reh;ibiiitHt[(Hi

i:i

the

IJeme

Pregv/ini,

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tbr

Sari)it'ePi'ot,idoi:s'

to

Communitv

Care

129 Web

sites of