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Helen Jarvis, Program Manager, Central Intake Referral Team, Ballarat Health Services delivered the presentation at the 2014 Discharge Planning Conference. The 2014 Discharge Planning Conference - Assisting health services to adopt an integrated and consumer directed approach to discharge planning. For more information about the event, please visit: http://bit.ly/dischargeplan14
Electronic Tools to Assist with Discharge Planning
Helen Jarvis
Program Manager Central Intake and Post Acute Care
24th July 2014
BALLARAT
Ballarat is one of Australia’s fastest growing cities with
more than 2,000 people moving to Ballarat each year.
BALLARAT
Ballarat Health Services is Victoria’s
second largest regional health
service, providing a comprehensive
range of general and specialist care
across key medical and healthcare
disciplines including acute care, sub-
acute care, residential aged care
services, community care, mental
health, dental and rehabilitation
services. In 2012/13 there were
32,355 inpatient separations and
53,308 attendances at the
Emergency Department.
BALLARAT
Central Intake and Post Acute Care
Central Intake
Central Intake is an access and referral management service providing consumers/carers/patients
with a single point of entry to those programs within the scope of Community Programs as well as
facilitating navigation of the broader community service system
Central Intake Referral Sources Email Fax In Person Internal Mail Phone Total
Community Programs 5098 1881 16 958 133 344 8430
Allied Health 654 3577 8 4291 898 36 9467
GRAND TOTAL 5752 5458 24 5249 1031 380 17897
Post Acute care
The Post Acute Care (PAC) program assists patients to recuperate following an acute hospital
admission, sub acute admission or an emergency presentation and to facilitate their
independence or transition to continuing care.
E-Referrals
What do we want in a E-Referral System?
Easy access
Improve efficiency of referral procedure
Eliminate duplicate data entry
Minim Data Set should be transferred from one system to another without the clinician keying anything in
You should be able to confirm that the referral has been sent and acknowledged
Rely on minimal training & expertise
Provide statistical information
Simplify transfer of information
Electronic Referral System
Referral Information Management System (RIMS)
The RIMS electronic referral system was initially trialled in the sub acute sector of Ballarat Health
Services and was formally adopted mid 2005
System for collecting, sending & storing referrals electronically
Primarily based on SCTT tools
Supports secure email, Autofax & printing
Pop-up calendar function on all date fields
Auditing at the referral, provider and form level
Facility to flag forms intentionally not completed
“Lock down” facility to restrict forms to read only after sending
Facility to supersede forms to generate a duplicate for editing after sending
Facility to transfer form definitions between RIMS installations
RIMS
Patient
management
System
PAS
Connecting Care
Service Provider
Pathway
Key Benefits
Streamlined data entry and better data quality
Linked to patient management system to provide demographic and episode data and
integrated with Connecting Care.
The forms required by each agency are automatically generated by the system,
Referrals are stored electronically to enable analysis of referral activity;
The user interface guides users to complete relevant fields based on the information
needs of the receiving service provider;
Forms can be emailed to agencies using Public Key Infrastructure (PKI) encryption
capability through the Connecting Care system, otherwise they are able to be
automatically faxed through a standalone electronic fax management system, or
printed and manually faxed or mailed out.
RIMS Referrer Statistics Department Referrals
Post Acute Care 1128
Social Work 876
Emergency 838
Central Intake 634
HARP 609
3 North 467
2 North 271
4 South 259
Hospital in the Home 244
ACAS 217
Inpatient Rehabilitation 186
Occupational Therapy 178
Gandarra Palliative Care 158
3 South 157
Transition Care 157
4 North 100
Geriatric Evaluation & Management 67
Rehab in the Home 67
Cognitive Dementia & Memory Service 21
Diabetes 21
Domiciliary OT 20
Jim Gay Unit 20
2 South 17
Wound Care CNC Team 16
PDPU 14
Midwifery 4
Clinical Services 3
Dialysis 3
Outpatient Department BH 3
Information Technology 2
Psychiatric Services 2
Acquired Brain Injury Clinic 1
Total 6760
Provider Referrals
Ballarat District Nursing And Healthcare Inc. - Nursing 912
Ballarat Health Services - Community Programs - Central Intake 902
Ballarat Health Services Post Acute Care 694
City of Ballarat Council - Home Care 654
Ballarat Health Services - Base Hospital - Respite care - Aged Care Assessment Service 561
Ballarat Health Services - Hospital Admissions Risk Program 371
Ballarat Health Services - Continence Resource Centre 365
mecwacare 207
City of Ballarat Council - Home Maintenance 173
Ballarat Hospice Care Inc - Palliative Care 166
Ballarat Health Services Carers Choice Grampians Region 157
Homecare Plus 108
City of Ballarat - Meals on Wheels 92
East Grampians HS Post Acute Care 76
Ballarat Health Services -TCP & RC 74
Maryborough District Nursing Service 69
Moorabool Shire Council - Home Care Assistance 64
Hepburn Shire Council - Home Care (Housekeeping Assistance) 55
Maryborough Post Acute Care 54
Ballan District Health and Care - Support groups - District Nursing Services 53
Djerriwarrh Health Services District Nursing 52
Hepburn Health - Daylesford District Nursing Services 48
Ballarat Health Services - Central Intake for Community Programs - Dietetics 45
Golden Plains Shire Council - Home Care 36
East Grampians - District Nursing Service 35
Beaufort District Nursing Service 28
Ballarat Health Services - Central Highlands Coordinated Community Care Linkages 27
Stawell Regional Health - Post Acute Care 27
Stawell Regional Health - District Nursing Service 23
St John of God Hospital Ballarat - Home Nursing Service 22
UnitingCare Ballarat - Do Care 22
RIMS Provider Statistics
Issues
Varied computer skills
Computer access
Currency of PAS information
Confirmation of e-referrals
Policies & Procedures in place for receiving
e-referrals
Cost of Discharging Problems
Readmissions
For the person to be referred to the right
program:
- Hospital admission risk program
- Hospital in the home
- GITH
- TCP
- Restorative Care
- HACC services
- District nursing
Easy access
Improve efficiency of referral procedure
Eliminate duplicate data entry
Minim Data Set should be transferred from one system to another without the clinician keying anything in
You should be able to confirm that the referral has been sent and acknowledged
Rely on minimal training & expertise
Provide statistical information
Simplify transfer of information
What do we want in a E-Referral System?
E-Referrals
Has been in use across Victoria for over 14 years as an online Service Directory and secure
referral and messaging solution.
Is now using the National Health Services Directory (NHSD) as its source of agency, site and
services information.
The NHSD is national asset content managed by a range of organisations and is used by a
wide range of applications for definitive information.
Now sends to and receives secure messages from Argus using sites. Argus is a major
secure messaging system used by thousands of GP, Specialist and Private Allied Health
practices.
Will soon be launched nationwide, allowing a much wider range of medical, primary care and
community services organisations to use secure messaging to better coordinate care across
the spectrum of Spectrum of Services.
Has adopted the national eHealth standard called SMD (secure message delivery) to allow
this messaging to and from GPs.
Connecting Care
RIMS
Patient
management
System
PAS
Connecting
Care
Service Provider
National Health
Services Directory
(NHSD)
Pathway
Referral Information
Management System
Referral Information
Management System
Referral Information
Management System
1. Drivers for change
Identified need to reduce the burden on the ward staff making referrals
A review of RIMS found that over the last 3 months ward staff completed 489 referrals to
PAC and Central Intake alone. This is conservatively estimated at 80 hours of data entry.
Our Health Independence Programs, which include HARP, PAC, Centre and Home Based
Rehabilitation programs and Specialist Clinics, need to streamline intake in preparation for
Activity Based Funding and to meet the requirements of the Department of Health.
Central Intake
Screening Tool
2. Aims
Introduce a system that:
- Requires ward staff to identify patient needs rather than specific
funding and program requirements
- Allows the Referral Team to screen patients and complete referrals
- Supports expansion to remaining Health Independence Programs.
Simplify the referral process and provide additional resources to complete referrals
into PAC and HARP.
Reduce the number of queries about referrals made to PAC and HARP.
Central Intake
Screening Tool
Assess
Coordinate
Communicate
Clarity over role
All Referrals apart from District Nursing and Palliative Care
Central Intake
Referral Team
Screening Tool
Guidelines Documentation on the Screening Tool and Referrals will be ISBAR which is the endorsed
communication tool across Ballarat Health Services
I- Identify Yourself and Patient (using 3 patient identifiers).
S- Situation State the immediate issue/Current situation.
B- Background Relevant past history.
A- Assessment Provide your assessment of the Patient’s current status.
R- Request Be clear about what you are requesting.
Responsibility for actions and clear timeframes.
Central Intake
Referral Team
6.2.1 The workforce has access to documented structured processes for clinical
handover that include:
Preparing for handover, including setting the location and time while maintaining continuity of patient care
Organising relevant workforce members to participate
Being aware of the clinical context and patient needs
Participating in effective clinical handover resulting in transfer of responsibility and accountability
National Safety and
Quality Health
Service Standards
Consumer Information
Service Coordination Tool Templates 2012
The Service Coordination Tool Templates (SCTT) is a
suite of templates developed to facilitate and support
service coordination.
Consumer Consent
Service Coordination Tool Templates 2012
The SCTT support the collection and recording of initial
contact, initial needs identification, referral and
coordinated care planning information in a standardised
way.
Summary and Referral
Service Coordination Tool
Templates 2012
Using the SCTT can improve
communication between
service providers, the recording
of information generated by
screening and assessment
processes, information sharing,
and the quality of referrals and
feedback between service
providers. This can assist
service providers to share
relevant information to support
better outcomes for consumers.
National Health Services Directory (NHSD) http://www.nhsd.com.au/
Connecting Care A comprehensive web-based directory providing secure messaging and e-referral
https://www.connectingcare.com/
Department of Health State Government of Victoria, Primary Care Partnership, Service Coordination Tools
http://www.health.vic.gov.au/pcps/sctt.htm
Useful Links
