HACC Services Review Indigo Shire
Indigo Shire Council Offices Beechworth
Glenview Community Care Rutherglen
Beechworth Health Services
Contents
1. Introduction
2. Executive Summary & Recommendations
3. Background & Scope of Project
4. Home and Community Care Literature Review
5. Methodology & Data Collection
6. Central Intake
7. Integrated Service
8. Developing effective Tools
9. Planning process
10. Conclusion
Appendices
1. Proposed IHA TOR
2. Central Intake Model
3. Planning Document.
4. Evaluation Tool
5. Quantitative Data Analysis/Referrals
6. Qualitative Data Summary
References
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1.0 Introduction
Indigo Shire is located in the North East of Victoria with a supportive tourist economy, strong agricultural base and a large wine producing industry in the Rutherglen region. The shires of Towong, Wodonga & Wangaratta, border the Indigo shire. Approximately 60% of the population is based in the main areas of Beechworth, Chiltern or Rutherglen with total population of 14,891. Population demographics indicate that in 2001, 19% of the population was aged over 60. By 2021 it is expected that this will increase to 30% of the population.
In terms of Home & Community Care (HACC) services there are three main providers within the Shire.
Glenview Community Care provides: District Nursing Planned activity Groups Assessment and Care Management.
Beechworth Health Service provides: District Nursing Planned Activity Groups Podiatry Assessment and Care Management.
Indigo Shire provides: Personal Care Home Care Respite Care Property Maintenance Meals on Wheals Assessment and Care Management Planned activity groups Volunteer support.
The three providers of health services have initiated, through a consultative and respectful process a common approach to health service delivery in the Indigo Shire that is underpinned by the DHS document “Rural Directions- A better State of Health,” November 2005. The document provides clear direction on the future of service delivery in the State of Victoria with the statement “Creating solid partnerships between different health services will help people get care as close to home as possible”.
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The aim of the project is to office recommendations for the three key Indigo Shire health providers to enable them to strategically partner for the future in a cohesive and constructive manner in delivering HACC services in the Indigo Shire.
The three key health providers in the Indigo Shire initiated the project, and identified the need to structure HACC services to better meet the demands of clients and providers alike early in the planning process. It was proposed that the key health providers would progress from an integrated services planning group to a more formalised structure very early in the consultative discussions with the executive. This structure will be described as the Indigo Shire Health Alliance (IHA) and is described further on in the report. The aim of the project is to offer recommendations for the Indigo Shire health providers to enable them to strategically partner for the future in a cohesive and constructive manner in delivering HACC services in the Indigo Shire.
2. Executive Summary & Recommendations.
An interest in understanding how HACC Services might be coordinated and directed towards improving the health of the Indigo Shire community was the basis for this HACC review.
At the inaugural meeting the integrated service planning group focused on the current documents released by the Department of Human Services. (DHS). Documents desirable to be included in the review as guiding direction and policy were the “Ambulatory Care Framework” the “Rural directions- For a Better State of Health” and the recent document “Strategic Directions in Assessment, Victorian Home and Community Care Program”. These documents were considered to be imperative frameworks for the integrated services group to utilise for the review and determine outcomes that were favourable to the community.
The integrated services planning group-reviewed data collected from a wide range of stakeholders, staff, volunteers and consumers. Workshops held in conjunction with the group management meetings offered an opportunity to hear about a variety of community experiences around HACC services. Consultation with these groups clearly indicated a need for a more streamlined approach to the assessment of HACC clients.
Anecdotal and qualitative evidence concluded that there were significant discrepancies within the Shire in the delivery of HACC services. On the basis of the information received from workshops,
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individual interviews and committee consultation, several recommendations were nominated for inclusion in the report and will be discussed further in the document
It is anticipated that agencies will not see the outcomes of this report as an opportunity to establish cost saving demands. It is about developing healthy client outcomes in the community and creating collaborative partnerships for the betterment of the client. It is therefore with confidence that the recommendations indicated below are made:
Recommendation 2.1
Develop a proposed Central Intake Model (CIM) for service delivery. It is expected that the model be drafted by the poposed IHA. The model will have input from staff within the Indigo Shire. A proposed draft HACC CIM is included as Appendix 2. The proposed CIM draft flow chart was developed as a work in progress for the IHA. (See section 6)
Recommendation 2.2
Beechworth Health Services, Indigo Shire and Glenview Community Care form an Indigo Health Alliance (IHA) for the Indigo Shire. The group will have formalised Terms of Reference and will work towards the betterment of care to clients in the Indigo Shire. It is expected that all decisions regarding future service expansion and delivery for HACC services will be made by this Alliance. Proposed IHA, Terms of Reference (TOR) is attached as Appendix1 to this document. (See section 7)
Recommendation 2.3
A comprehensive suite of tools is sourced to work with and complement the SCOT tool and that the process be guided by the proposed IHA as an priority of the newly formed partnership. (See section 8)
Recommendation 2.4
IHA establish a planning document that will be used to guide development of the newly formed service. The planning document will include:-
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• Strategies to pool funds for more efficient use of health resources • Working closely with those who are not funded • A communication strategy to inform the community about improvements to the HACC assessment and intake system • Change management strategy for staff and the community. • Proposed comprehensive Evaluation Tool to enable the process to be soundly evaluated as a component of the ongoing Alliance outcomes. (See section 9)
A proposed draft Planning Document & Evaluation Tool developed by IHA is attached as Appendices 3 and 4.
3. Background and Scope of Project.
The Home and Community Care (HACC) programme was introduced as a Federal Legislative Act in 1985 to develop a comprehensive range of integrated services to assist frail older people and people with disabilities to remain in their own homes and in the community. In 1991National HACC Service guidelines were introduced to provide the basis for a nationally consistent approach to the quality and delivery of all HACC funded services.
A literature review conducted on community service delivery recognised that a streamlined intake & assessment system was a concept that was being developed across numerous countries and was supportive of the current move towards creating efficiencies and equity of service to the community.
The HACC service system currently incorporates a large number and a diverse range of service providers involved in the delivery of HACC services. The following are designated HACC services:- • Assessment & Care management • Personal care • Volunteer co-ordination • Planned activity groups • Linkages • Home care • Respite care • Property maintenance • Nursing Support
In recent years, ongoing escalating change and expansion has had significant impact on the level, range and types of HACC service
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provided. Consequently the rate of expansion of services has had a major impact on the role and functions of program staff.
Increasingly high demand on HACC services, rapidly increasing numbers of high complex needs clients, increasing accountability in reporting requirements has had significant impact on service delivery and staff morale. Through this project the proposed IHA has indicated that issues of access, equity, consistency of service, service allocation and creation of efficiencies will be addressed.
The project included all HACC funded agencies within the Indigo Shire inclusive of Beechworth Health Service, Glenview Community Care and The Indigo Shire component as a provider of health services. Recipients of HACC services were also included in the consultations.
4. Home and Community Care Literature Review
The aim of the HACC review is to engage with the three principal HACC service providers in the Shire of Indigo (Beechworth Health Service, Glenview Community Health Services and Indigo Shire Council) to identify a need for clear points of access to the health and support services provided in the shire. It is within this context that the literature review will sustain the group to develop a consistent understanding of the meaning of service coordination and how it is accomplished in other countries. The literature review also looks at assessment strategies used to enhance service provision in other ways.
This segment attempts to review across the continent assessment and service coordination of health services for older people. The review begins with a selection of service co-ordination and assessment trends across countries that may be pertinent to the project and/or inform the working group.
This paper does not include the current Care Coordination Framework that is work in progress by the Department of Human Services (DHS) at the time of the review. The framework will have to be discussed within the context and the objectives contained within the framework if the group consider this to be a viable option.
The review will focus on general national service co-ordination and integration strategies of a number of countries. These include Australia, Canada, United Kingdom, Japan, Germany, Denmark, United States and New Zealand.
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A description of Home and Community Care (HACC) services is required to establish the context for the literature review. HACC services are a service provided by the Commonwealth in partnership with the state government to supply varied health services to the community. These services range from:
• Help around the home • Personal, nursing and health care • Help to get out and about • Assistance with respite care • Help for older people with complex needs
Regular assessments are required to access a HACC service and the service may be obtained through the local council, community health centre and District Nursing services. Consistent with this description is the attempt by the three services providers to establish clear links of communication, assessment protocols and service coordination.
Coleman in her article “European Models of Long Term Care in the Home and the Community” has observed that governments in the countries of Sweden, Denmark, Netherlands and the United Kingdom have shifted greater responsibility to local governments for delivering long-term care services through:
• Bringing those services closer to those who need them • Management strategies that have enabled care providers to better target appropriate services for elderly clients. • Incentives for different types of care providers to coordinate their work, resulting in improved service delivery and greater client satisfaction
Within Australia, Butler et al in their review of international literature on the assessment of the elderly identified a number of trends in countries, which have striven to overcome the problem of fragmentation of services (although there is no single agreed route). The trends are nominated as:
• A single, local focus for care management and service coordination • A holistic view of needs • Linking services and family care
The Netherlands however have combined entitlement with a discretionary process of assessing eligibility that identifies as key components a more improved service delivery method of:
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• Evaluation of the reliability of assessment tools • Ensuring access to fragmented services is better co-ordinated.
Butler et al further articulates that recent literature on approaches to assessment trends centres on three key areas and Butler argues that more practical research is required in these areas- of assessment, in particular how it is carried out in practice and the skill level required to carry out the assessments. Tension between clinical medical and social approaches to assessment impedes smooth assessment transition and access for clients.
Coordinated Care Trials were an initiative of the Australian government. The premise was that care coordination would reduce hospital admissions. Phase one commenced in 1994. These early coordinated care trials for various reasons proved disappointing.
However Phase two was commenced in 2002 and is due for completion late 2005. Esterman and Ben-Tovim described the outcome of Phase one in an editorial; “The possibility remains, however, that the essential premise that better coordination reduces hospitalisation is misguided. It may be that lack of coordination in a complex care system operates as a functioning rationing system, so that better care coordination reveals unmet needs rather than resolving them. Experience in the mental health field implies that this may be so” Phase two trials in Australia have indicated that effective service and care coordination requires an effective primary care team approach, in which GP’s play an important and integral part and there are also indications that local ownership of coordinated processes is very important and would need wide ranging agreement between providers clients and differing levels of government (World Class care, PP, 66).
The analysis paper ‘Impacts of Service Coordination on Service Capacity in the Primary Health Care Sector” documents clearly that service coordination provides the means by which agencies can come together to develop localised systems and processes and further writes that enhanced flexibility of service responses, single points of entry, increased partnerships between providers and sectors and greater alignment of service structures and supports are the medium to longer term benefits that are expected to be derived from increased participation in service coordination. (KPMG, Executive Summary, P.1.2004)
The government of Quebec is moving into- an integrated service delivery model for the elderly. This model will provide for an
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integrated system of service delivery with single entry and ongoing case management for a full range of community and facility based care. The essence of the reform was to ensure that multiple services have a single point of entry with “one stop shopping”. This may be done through allowing the not for profit sector to tender for the right to deliver the coordination of the differing health service products in the community. (Hollander. p.12).
In Japan local councils have had a key role in planning and coordination at the local level due to their close contact with residents. Local councils are responsible for service provision and the formulation of community care plans. This is in contrast to Australia for example where local-level coordination relies on GP’s and Aged care assessment teams (Nishimura conference, p. 59)
In Germany the trend is towards HACC styled service provision for community care consumers. As a general rule home care is preferred to institutional care and prevention and rehabilitation is given priority over institutional care. Coordination is effective and consumers may choose freely between nursing homes and home care agencies. Consumers electing home and community-based services choose providers that have contracts with funding holders. As with HACC all assistance with community and health services is available.
Conclusions
While the Literature review is brief in nature it is consistent with the length and depth of the Home and Community Care (HACC) Service coordination review. The Literature review has identified that Service coordination is a trend that is occurring in most health services in most countries. The methods of service coordination are similar in that they all focus on a need for a single point of entry that simplifies access for the client. It also appears that the “One Stop Shop” service coordination concept also de-stresses staff who attend to the assessments of clients.
5. Methodology and Data Collection
Collaborative workshops were held at Rutherglen and at Beechworth to facilitate the data collection process. Participants included staff from various health centres, management and consumers inclusive of those who were services recipients.
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The workshops were specifically designed to collect data related to outcomes nominated in the project brief. Participants at both workshops indicated a need for HACC service review and were very willing to participate in the process.
Individual interviews were held with HACC Assessment Officers and District Nursing services to ensure that data collection was comprehensive and inclusive of all staff working in HACC provision in the Indigo Shire.
A review of reports provided by DHS were also utilised by the consultant to facilitate and support discussions held with the Indigo Health Alliance.
An analysis of quantitative data of referrals and assessments in the Indigo Shire is provided as Appendix 5
A collaborative and consultative approach was utilised by the project to ensure that HACC service providers and recipients were included in the overall approach. The project progressed through the following phases:
Phase 1
An initial discussion with Department of Human Services (DHS) Representative and the Indigo Health Group participants to:
• Define the outcomes of the project • Identify the participants • Obtain contact information
Phase 2
Communication and Consultation with community and staff participants inclusive of:
• Key Stakeholders Workshops • Individual Interviews • Group Discussions (IHA) • Data Collection
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Phase 3
• Collation of qualitative and quantitative data provided by all participants and the Department of Human Services & Health. • Evaluation tool and planning document provided as appendices that will further facilitate on going progress and implementation of the report. • Report and recommendations set out in this report.
6. Central Intake
The array of influences on health, identified by the consultancy also suggests that there are many public and private entities that have a stake in or can affect the community’s health. These stakeholders can include health care providers (eg: clinicians, health plans, hospitals) public health agencies and community agencies specifically concerned with health. Many of the agencies have a local base and focus. Others may play an essential role in shaping health at a broader level such as the Department of Human Services at metropolitan level as well the department of Health & Aging (DOHA) at Commonwealth level.
Health improvement strategies should seek to apply available resources as effectively as possible, given a communities specific features. A community must assess resources available for health improvement efforts. Relevant resources include those that can be applied to required tasks and those that can collaborate to enure that services are delivered in a timely and consistent manner.
Once the community has targeted an issue, the health improvement process proposed by the integrated service planning group and the stakeholders stimulates a series of phases for consideration and development. Priority should be given to actions that will be effective in the workplace and will have definitive outcomes for the community.
The integrated service planning group, through its community health directives will assist the process of the development of a framework such as a Central Intake Model.
Therefore it is a recommendation of this report that a single point of contact for clients to access HACC services in the Indigo Shire be developed. The integrated services working group have made constructive decisions about who would manage this process of “ managed client intake” and Indigo Shire was the provider of choice.
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The proposed Central Intake Model Flow Chart was developed as a work in progress for the IHA as an agreed starting point.
The Central Intake Model flow chart is designed to complement the Care Planning and Coordination Overview Flow chart designed by the HACC Best Practice Project and is included as an Appendix 2
7. Integrated Service Development
As communities try to address their health issues in a comprehensive manner, all of the stakeholders will need to sort out their roles and responsibilities, which will vary from community to community. These interdependent sectors out of necessity are obliged to address issues of shared responsibility for various aspects of community health and individual accountability within the various communities.
The integrated service-planning group proposes a comprehensive strategy for meeting the health challenges that rural communities face. Some of the challenges stem from lack of knowledge in accessing core health care services, such as HACC services in the community. Overcoming these barriers will require an integrated approach to meet personal and population needs at the community level; assist health systems professionals to acquire the knowledge and tools to improve quality; and enhance education and training to increase the supply of health professionals in rural areas.
Most health providers and communities will have only limited experience with collaborative and coordinated efforts to streamline care. Effective coordination will require a common language that will enhance service delivery to the community. It is an iterative and evolving process rather than short term.
Therefore a recommendation of this report is for Beechworth Health Services, Indigo Shire and Glenview Community Care to form an Indigo Health Alliance (IHA) for the Shire. The group will have formalised Terms of Reference and will work towards the betterment of care to clients in the Indigo Shire. It is expected that all decisions regarding future service expansion and delivery for HACC services within the Indigo Shire will be made by the Indigo Health Alliance.
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8. Developing Effective Tools
In the course of the work undertaken in the project, a shared awareness of the way in which HACC services were being utilised and managed in the Indigo Shire became apparent. Beyond the usual strategies others need to be developed to ensure an efficient and timely service to the clients is achieved. Increasing complexity of care is impacting on the assessment process as well as holistic care prerogatives and evaluation and review components of the assessment process.
The current assessment activities are not as efficient as the individual HACC providers would have like them to be and the current process is also impacting on the assessment officer’s ability to perform assessment roles in a satisfying way. Assessment activities should facilitate the flow of information among service providers and the information gathered through the data collection process must feed back into the system to ensure adequate planning occurs.
To facilitate this process adequate tools are required to support and enable the system to operate effectively.
Therefore it is a recommendation of this report that a comprehensive suite of tools is sourced to work with and complement the SCOT tool and that the process is guided by the proposed IHA as a priority of the newly formed partnership.
9. Planning Process
Until now the Indigo health providers have delivered their roles and responsibilities separately from each other and often from the rest of the community as well. However working alone and independently, formal health systems find it difficult to improve outcomes.
The Indigo Health Alliance has identified a need to invest in a process that mobilises expertise and forms strategic direction to the betterment of the Indigo Shire. The formation of the Indigo Health Alliance will facilitate the process of change. A strategy for performance monitoring, increasing skill levels for assessment and care staff and sharing of resources can be developed further.
Establishing accountability through a collaborative approach is a key to continue to contribute to health improvements in the Indigo
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Shire. Implementation of health and process improvement strategies is under way and performance monitoring becomes an essential guide. Information provided by the performance indicators should be reviewed regularly by the proposed IHA and used to further enhance service delivery.
The quantitative data (for example as supplied in Appendix 5) provided as performance indicators should be interpreted in combination with qualitative data as supplied by the community, as was the case in this report. Therefore to facilitate the ongoing process of service development and to assist the proposed IHA in the first few months of it’s inception it is:
A recommendation of this report is that the IHA establish a planning document that will be used to guide development for the newly formed service. The planning document will include; • Strategies to pool funds for more efficient use of health resources • Working closely with those who are not funded • A communication strategy to inform the community about changes to the system • Change management strategy for staff and the community. • Evaluation process
A draft-planning document developed by IHA is attached as Appendix 3.
10. Conclusion
To maintain momentum for the proposed Indigo Health Alliance, it was considered reasonable to select problems that are amenable to change and success in the short term. The balance may be achieved by including the interim goals in the form of a key-planning document to guide activities in this formative stage. It is envisaged that the proposed IHA will strive for strategic inclusiveness, incorporating individuals groups and organizations that have an interest in service and health outcomes. To this end it is timely to note that the Chiltern hospital has recently ceased as an inpatient facility. The management of this hospital has stated publicly that it wishes to replace its bed-based services with community-based services. It is important that IHA to note this and to include the chiltern service provider in its deliberations less further duplication arises. All community initiatives require leadership and the proposed IHA recognise that the way forward is a collaborative effort.
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Appendix 5 and 6 provide qualitative and quantitative data that further inform the report.
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Appendix 1
Terms of Reference for the proposed Indigo Health Alliance
The Indigo Health Alliance (IHA) committee is a strategic and advisory committee to assist and develop health services in the Shire of Indigo.
The aim is to address identified key areas in the planning document utilising the principles of collaboration and partnerships, access and equity, community development and sustainability.
The role of the IHA is to improve collaboration between health agencies and the community and to engage with stakeholders to facilitate sustainable partnerships to drive the implementation and further development of the IHA Planning document.
Membership shall include an executive management member of Glenview Community Care, Beechworth Health Services and the Indigo Shire. The Committee shall be known as the Indigo Health Alliance (IHA) others shall be nominated to the committee as required by the IHA.
Working Teams may be established by the IHA to achieve specific aims and objectives. The teams will comprise of IHA members and others nominated to achieve the desired outcomes. The IHA coordinator will chair and report on the team outcomes to the IHA.
Objectives are to: Meet bi-monthly to ensure that planning objectives and strategic direction are met.
Ensure that there is a communication plan that promotes open and regular communication through the coordinator and members to boards, stakeholders and the public.
To appoint, monitor and support the IHA coordinator position.
To establish working parties as needed and directed by the IHA.
Consider any matter brought to the attention of the IHA by the Coordinator of the IHA directives.
Make recommendations to respective governing bodies as to the direction of collaborative efforts.
Advocate for strong community engagement and agency participation to address key result areas identified in the plan.
Advocate for financial and other resources that will underpin the planning document and assist with service growth. Revise the Planning document annually and develop further strategic direction of the IHA. Provide the IHA coordinator with strong leadership and identified needs to address.
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Appendix 2. Central Intake Model
Indigo Health Alliance (CIM Model Flow Chart)
All HACC Referrals Consider Care Planning and Coordination Overview Flow Chart HACC (DHS)
Central Intake Indigo Shire (1300 Number) Urgent need Referrals direct to Clinicians
Back to Assessment SCTT Tool (1st 2 Pages)
Data Collection Feedback Assessment Officers and Care Coordinators Indigo, Glenview, Beechworth
Relevant Agency for Specific Care
Client Exits
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Appendix 3 Planning Document Proposed IHA Planning Document 2006-2008
Summary
This document is the conceptual planning document for the proposed Indigo Health Alliance. The IHA primary function is to lead and provide the necessary framework for successful health planning that will further enhance HACC services in the Indigo Shire. HACC services in the Indigo shire make a crucial contribution to improving the lives of whole families and minimising costs to the community and health service providers.
The strategic context in which this year’s plan will be changed differs markedly from previous years due to the collaborative focus as opposed to the individual health provider focus. This strategic process provides a welcome opportunity to share the success of individual providers in the creation of a new Alliance that will be efficient, cost effective and appropriate to the wider needs of the Indigo Shire community.
It is proposed that this document become a template for the proposed IHA to establish a clear and focused vision for the proposed new Alliance. Significant progress has been achieved in determining the strategic goals for the proposed IHA however operational goals may be developed further to support growth.
IHA Outcomes
• To build a strong and effective HACC service delivery framework for the Indigo Shire. • To develop and maintain an effective intake and assessment model. • To strengthen the decision-making and planning processes for the Indigo Shire through the development of the proposed IHA.
IHA Mission
To Manage HACC service provision co-operatively for today and tomorrow for the benefit of the community.
IHA Strategic Objectives
1. Advance the progress of IHA through the formal establishment of a memorandum of understanding.
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2. Manage the Central Intake Model (CIM) development and implementation over the course of time.
3. Ensure that administrative functions are available to support the continued development of the key strategic goals of the IHA.
4. Investigate possibilities that will assist the IHA to make possible the collaborative utilisation of funds.
5. Develop a strategic focus for the development of information management and technology requirements that will support the CIM.
6. Encourage, facilitate and promote exploration and development of the education plan for the IHA. This objective will support staff education and development.
7. Encourage, facilitate and promote a key strategy around communication to the wider community, service providers and staff.
Strategic and Operational Goals for Consideration (2006- 2007)
1. Advance the progress of IHA through the formal establishment of a memorandum of understanding & terms of reference (short term).
Operational Goals • Develop memorandum of understanding • Develop Terms of reference • Acceptance of Strategic goals of the Planning Document as a way forward.
2. Research and implement the collaborative use of HACC funds across the IHA (short term and long term objectives).
Operational Goals • Calculate the Total HACC funds available and consider strategic combinations to pool funds • Develop a plan for proposed use of funds • Implement and evaluate the process and use of funds.
3. Manage the Central Intake Model (CIM) development and implementation over the course of time (short term).
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Operational Goals • Draft CIM accepted and endorsed by IHA • Model trialled & evaluated over a nominated period • Develop rollout strategy based on evaluation data • Source funding to support the key deliverables nominated in the Model Development.
4. Ensure that administrative functions are available to support the continued development of the key strategic goals of the IHA (short term and long term objectives).
Operational Goals • Develop clarity in administrative support functions for the IHA • Second an administrative member to assist with coordination and strategic deliverables for the IHA.
5. Develop a strategic focus for the development of information and technology requirements that will support the CIM (short and long term components).
Operational Goals • Source expert IT advice to develop action plan to support the CIM model development and strategic change • Source funding that will drive the IT development and support for the CIM • Develop relationships with a provider of choice to support IT direction.
6. Encourage, facilitate and promote exploration and development of the education plan for the IHA. This objective will support staff education and development of HACC staff (long term goal).
Operational Goals • Establish links with and support from the HACC education program • Investigate outsourcing education as a component of education development • Investigate how pooling of funds will assist this process.
7. Encourage, facilitate and promote key strategies to meet the communication needs of the IHA and the wider community, service providers and staff (short & long term components).
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Operational Goals • Develop communication strategy to assist with dissemination of information about Key strategic changes.
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Appendix 4 Evaluation Tool
Evaluation Model for Improving Health Care (Changing culture)
“Generally, in this era of evidence based everything we all need to be able to better justify our proposals and ideas with evidence…” Prof John Ovretveit
Concepts
Why Evaluate? To get successful change, design the change so that it can be evaluated. Evaluation closes the Quality loop The link between culture and evaluation = successful change implementation
Intervention The thing being evaluated (What is done to change what otherwise would not have happened?). Intervention Actions: For example, Service model like Multi Disciplinary Team introduced, or change to the Organisation, or Finance
Helping & What helps and/or hinders in applying the intervention Hindering Factors Outcomes The difference the intervention makes Outcomes are defined by the data collected.
Criteria & Stakeholders: Those who think they gain or lose from the Stakeholders intervention What do the stakeholders value about the intervention? (the fewer stakeholders the better)
Attribution Deciding what caused the outcomes - the intervention or something else.
Confounders Other things that could explain the outcome.
Controls What we do to control the influence of confounders.
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Nine Steps to Planning and Doing an Evaluation
Step 1 Make your first guesses about Define constraints the constraints that may influence your evaluation. For example, time, people, budget, available data, etc. Step 2 Components: break it down into Define Intervention main parts/activities Scope: define what is and what is not evaluated. Step 3 Who is the evaluation for? (hint: Decide user and criteria. choose one user group) What information could inform their actions? What is important to them about the intervention? Step 4 Collect data about what was Define data needed and implemented/the intervention - collection methods. ‘evidence’ Collect data about outcome(s). Step 5 Time perspective: Decide design For example, retrospective, prospective, during the intervention. Comparison: For example, before/after, before/after time series, comparative before/after, research, audit. Step 6 Recognise assumptions. Risk Management. Predict problems. Plan and manage risks. Step 7 For example: Gantt Chart. Timetable, tasks and responsibilities. Step 8 Measure what is important (not Collect Data easy) Allow time for data collection and data analysis.
Step 9 To whom, when and format. Reporting
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Six Shortcomings of Evaluations
• Not clearly describing the intervention actions
• Not describing the conditions under which the intervention was done
• Gathering too much outcome data
• Gathering too little outcome data
• Not defining the user(s) and their value criteria
• Assuming only the intervention could cause the outcome
Notes and Model with thanks to Professor John Ovretveit, Director of Research, Karolinska, Medical Management Centre, Sweden and Professor of Health Management, Faculty of Medicine, Bergen University, Norway.
See also: Ovretveit, J (2002) Action Evaluation of Health Programmes and Change – A handbook for a user focused approach. Radcliffe Medical Press Oxford
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Appendix 5 Quantitative Data Analysis/Referrals
HACC Service Review Indigo Shire 26 Chart 1 - Care Services delivered by HACC agencies - Shire of Indigo 2004/2005 Records by Location
Yackandandah (3749) 16.4% Chiltern (3683) 17.6%
Rutherglen (3685) 21.7%
Beechworth (3747) 30.8%
Wahgunyah (3687) 4.9% Sandy Creek (3695) 0.0% Barnawartha (3688) S.E Wodonga (3691) 3.4% 5.3%
Char271 Chart 2 - Care Services delivered by HACC agencies - Shire of Indigo 2004/2005 Home Care (Hours)
1198 1580
2822
2814
188
548 627
533
Chart 2 Page 2 Chart 3 - Care Services delivered by HACC agencies - Shire of Indigo 2004/2005 Volunteer Social Support (Hours)
40.2%
59.8%
Chart 3 Page 3 Chart 4 - Care Services delivered by HACC agencies - Shire of Indigo 2004/2005 Allied Health (hours)
290 280
216
385
37
39
69 86
Chart 4 Page 4 Chart 5 - Care Services delivered by HACC agencies - Shire of Indigo 2004/2005 Nursing (Hours)
526
1226 563
74
119
62
67
2296
Chart 5 Page 5 Chart 6 - Care Services delivered by HACC agencies - Shire of Indigo 2004/2005 Personal Care (Hours)
168 115
462 364
99 94
220 135
Chart 6 Page 6 Chart 7 - Care Services delivered by HACC agencies - Shire of Indigo 2004/2005 Planned Actvity Group (Hours)
1740
3405
3601
3615
25
281 159 314
Chart 7 Page 7 Chart 8 - Care Services delivered by HACC agencies - Shire of Indigo 2004/2005 Prop (Hours)
140
158
364
75
23
42
467 10
Chart 8 Page 8 Chart 9 - Care Services delivered by HACC agencies - Shire of Indigo 2004/2005 Meals Delivered (Number)
1785 1776
4071 3825
130 570
198 338
Chart 9 Page 9 Chart 10 - Care Services delivered by HACC agencies - Shire of Indigo 2004/2005 Respite (Hours)
100%
Chart 10 Page 10 Chart 11 - Care Services delivered by HACC agencies - Shire of Indigo 2004/2005 Assessment (Hours)
112 103
267
298
58 33
42 59
Chart 11 Page 11 Chart 12 - Care Services delivered by HACC agencies - Shire of Indigo 2004/2005 Case Management (Hours)
17 31
35
37
10
Chart 12 Page 12 Chart 13 - Care Services delivered by HACC agencies - Shire of Indigo 2004/2005 Counselling (Hours)
2 2
Chart 13 Page 13 Table A Total hours of Care Services delivered in 2004-05 by HACC agencies to clients in the Shire of Indigo by client postcode
Total Hours Volunteer Planned Case Home Allied Personal Assessmen Counsellin Delivered Social Nursing Activity Prop Respite Manageme Total Care Health Care t g Meals Support Group nt Location Hours Hours Hours Hours Hours Hours Hours Hours Hours Hours Hours Hours Number
Chiltern -3683 1,580 - 280 526 115 3,405 140 - 112 31 - 6,189 1,785 Rutherglen- 3685 2,814 - 216 563 462 3,615 158 - 267 37 2 8,134 4,071 Wahgunyah - 3687 627 - 37 74 94 281 75 - 58 - - 1,246 570 Barnawartha -3688 533 - 39 119 135 314 23 - 42 - - 1,205 338 S.E Wodonga -3691 548 - 69 62 220 159 42 - 59 - - 1,159 198 Sandy Creek -3695 188 - 86 67 99 25 10 - 33 10 - 518 130 Beechworth - 3747 2,822 698 385 2,296 364 3,601 467 5 298 35 2 10,973 3,825 Yackandandah. -3749 1,198 469 290 1,226 168 1,740 364 - 103 17 - 5,575 1,776 - 10,310 1,167 1,402 4,933 1,657 13,140 1,279 5 972 130 4 34,999 12,693
Number of Records Planned Case Home Allied Personal Delivered Volunteer Nursing Activity Prop Respite Assessme Managem Counselli Total Care Health Care Meals Social Group nt ent ng Location Records Records Records Records Records Records Records Records Records Records Records Records Records
Chiltern -3683 117 - 148 100 8 110 43 - 75 5 - 606 43 Rutherglen- 3685 259 - 110 130 33 131 70 - 145 5 1 884 89 Wahgunyah - 3687 57 - 17 27 7 47 30 - 28 - - 213 15 Barnawartha -3688 40 - 20 25 9 21 9 - 16 - - 140 9 S.E Wodonga -3691 48 - 28 16 12 5 14 - 39 - - 162 8 Sandy Creek -3695 13 - 10 11 3 3 5 - 11 4 - 60 3 Beechworth - 3747 229 10 108 266 27 220 133 2 208 10 2 1,215 88 Yackandandah. -3749 101 4 107 141 13 115 38 - 67 10 - 596 47 - 864 14 548 716 112 652 342 2 589 34 3 3,876 302
Average per record Planned Case Home Allied Personal Delivered Volunteer Nursing Activity Prop Respite Assessme Managem Counselli Total Care Health Care Meals Social Group nt ent ng Location Hours Hours Hours Hours Hours Hours Hours Hours Hours Hours Hours Hours Meals
Chiltern -3683 13.50 1.89 5.26 14.38 30.95 3.26 1.49 6.20 10.21 41.51 Rutherglen- 3685 10.86 1.96 4.33 14.00 27.60 2.26 1.84 7.40 2.00 9.20 45.74 Wahgunyah - 3687 11.00 2.18 2.74 13.43 5.98 2.50 2.07 5.85 38.00 Barnawartha -3688 13.33 1.95 4.76 15.00 14.95 2.56 2.63 8.61 37.56 S.E Wodonga -3691 11.42 2.46 3.88 18.33 31.80 3.00 1.51 7.15 24.75 Sandy Creek -3695 14.46 8.60 6.09 33.00 8.33 2.00 3.00 2.50 8.63 43.33 Beechworth - 3747 12.32 69.80 3.56 8.63 13.48 16.37 3.51 2.50 1.43 3.50 1.00 9.03 43.47 Yackandandah. -3749 11.86 117.25 2.71 8.70 12.92 15.13 9.58 1.54 1.70 9.35 37.79 - - 11.93 83.36 2.56 6.89 14.79 20.15 3.74 2.50 1.65 3.82 1.33 9.03 42.03 Summary 1 Page 1 Table 1: Total number of records in the HACC MDS for Table 2: Total hours of Home Care delivered in 2004-05 by HACC Table 3: Total hours of Volunteer Social Support delivered in 2004-05 for clients living in the local government area agencies to clients in the Shire of Indigo by client postcode 2004-05 by HACC agencies to clients in the Shire of Indigo of Indigo by postcode by client postcode Home Care Home care No. of Total No. of Ave. per Location No. of Records Location hours Records Ave. per record Location Hours Records record Chiltern (3683) 551 Chiltern (3683) 1,580 117 13.50 Rutherglen (3685) 680 Rutherglen (3685) 2,814 259 10.86 Wahgunyah (3687) 155 Wahgunyah (3687) 627 57 11.00 Barnawartha (3688) 107 Barnawartha (3688) 533 40 13.33 S.E Wodonga (3691) 166 S.E Wodonga (3691) 548 48 11.42 Sandy Creek (3695) Sandy Creek (3695) 188 13 14.46 Beechworth (3747) 965 Beechworth (3747) 2,822 229 12.32 Beechworth (3747) 698 10 69.80 Yackandandah (3749) 513 Yackandandah (3749) 1,198 101 11.86 Yackandandah (3749) 469 4 117.25
Total 3,137 Total 10,310 864 11.93 Total 1167 14 83.36
Table 4: Total hours of Allied Health delivered in 2004-05 by HACC Table 5: Total hours of Nursing delivered in 2004-05 by agencies to clients in the Shire of Indigo by client postcode HACC agencies to clients in the Shire of Indigo by client postcode Total No. of Total No. of Ave. per Location Hours Records Ave. per record Location Hours Records record Chiltern (3683) 280 148 1.89 Chiltern (3683) 526 100 5.26 Rutherglen (3685) 216 110 1.96 Rutherglen (3685) 563 130 4.33 Wahgunyah (3687) 37 17 2.18 Wahgunyah (3687) 74 27 2.74 Barnawartha (3688) 39 20 1.95 Barnawartha (3688) 119 25 4.76 S.E Wodonga (3691) 69 28 2.46 S.E Wodonga (3691) 62 16 3.88 Sandy Creek (3695) 86 10 8.60 Sandy Creek (3695) 67 11 6.09 Beechworth (3747) 385 108 3.56 Beechworth (3747) 2296 266 8.63 Yackandandah (3749) 290 107 2.71 Yackandandah (3749) 1226 141 8.70 Total 1402 548 2.56 Total 4933 716 6.89
Table 6: Total hours of Personal Care delivered in 2004-05 by HACC Table 7: Total hours of Planned Activity Group - Core agencies to clients in the Shire of Indigo by client postcode delivered in 2004-05 by HACC agencies to clients in the Shire of Indigo by client postcode
Total No. of Total No. of Ave. per Location Hours Records Ave. per record Location Hours Records record Chiltern (3683) 115 8 14.38 Chiltern (3683) 3,405 110 30.95 Rutherglen (3685) 462 33 14.00 Rutherglen (3685) 3,615 131 27.60 Wahgunyah (3687) 94 7 13.43 Wahgunyah (3687) 281 47 5.98 Barnawartha (3688) 135 9 15.00 Barnawartha (3688) 314 21 14.95 S.E Wodonga (3691) 220 12 18.33 S.E Wodonga (3691) 159 5 31.80 Sandy Creek (3695) 99 3 33.00 Sandy Creek (3695) 25 3 8.33 Beechworth (3747) 364 27 13.48 Beechworth (3747) 3,601 220 16.37 Yackandandah (3749) 168 13 12.92 Yackandandah (3749) 1,740 115 15.13
Summary 2 Page 1 Total 1657 112 14.79 Total 13,140 652 20.15 Table 8: Total hours of Personal Care delivered in 2004-05 by HACC Table 9: Total number of meals delivered in 2004-05 by agencies to clients in the Shire of Indigo by client postcode HACC agencies to clients in the Shire of Indigo by client postcode Total No. of No. of Ave. per Hours Records Ave. per record Location Number Records record Chiltern (3683) 140 43 3.26 Chiltern (3683) 1785 43 41.51 Rutherglen (3685) 158 70 2.26 Rutherglen (3685) 4071 89 45.74 Wahgunyah (3687) 75 30 2.50 Wahgunyah (3687) 570 15 38.00 Barnawartha (3688) 23 9 2.56 Barnawartha (3688) 338 9 37.56 S.E Wodonga (3691) 42 14 3.00 S.E Wodonga (3691) 198 8 24.75 Sandy Creek (3695) 10 5 2.00 Sandy Creek (3695) 130 3 43.33 Beechworth (3747) 467 133 3.51 Beechworth (3747) 3825 88 43.47 Yackandandah (3749) 364 38 9.58 Yackandandah (3749) 1776 47 37.79 Total 1,279 342 3.74 Total 12693 302 42.03
Table 10: Total hours of Respite - Home & Community delivered in Table 11: Total hours of Assessment delivered in 2004-05 by 2004-05 by HACC agencies to clients in the Shire of Indigo by client HACC agenciesto clients in the Shire of Indigo by client postcode postcode Total No. of Total No. of Ave. per Location Hours Records Ave. per record Location Hours Records record Chiltern (3683) Chiltern (3683) 112 75 1.49 Rutherglen (3685) Rutherglen (3685) 267 145 1.84 Wahgunyah (3687) Wahgunyah (3687) 58 28 2.07 Barnawartha (3688) Barnawartha (3688) 42 16 2.63 S.E Wodonga (3691) S.E Wodonga (3691) 59 39 1.51 Sandy Creek (3695) Sandy Creek (3695) 33 11 3.00 Beechworth (3747) 5 2 2.50 Beechworth (3747) 298 208 1.43 Yackandandah (3749) Yackandandah (3749) 103 67 1.54 Total 5 2 2.50 Total 972 589 1.65
Table 12: Total hours of Case Management delivered in 2004-05 by Table 13: Total hours of Counselling delivered in 2004-05 by HACC agencies to clients in the Shire of Indigo by client postcode HACC agencies to clients in the Shire of Indigo by client postcode Total No. of Total No. of Ave. per Location Hours Records Ave. per record Location Hours Records record Chiltern (3683) 31 5 6.20 Chiltern (3683) Rutherglen (3685) 37 5 7.40 Rutherglen (3685) 2 1 2.00 Wahgunyah (3687) Wahgunyah (3687) Barnawartha (3688) Barnawartha (3688) S.E Wodonga (3691) S.E Wodonga (3691) Sandy Creek (3695) 10 4 2.50 Sandy Creek (3695) Beechworth (3747) 35 10 3.50 Beechworth (3747) 2 2 1.00 Yackandandah (3749) 17 10 1.70 Yackandandah (3749) Total 130 34 3.82 Total 4 3 1.33
Summary 2 Page 2
Appendix 6 Qualitative Data Summary
Issues isolated and related to Current HACC Review:
• Inflexible service system about HACC services and delivery of those services. • The current system does not support equity of access to target groups • Broader issues include where the client lives as to what service they can access and what supports funds are available for clients. • Assessments are duplicated and not shared • Streamlining of client information that results in sharing of information. • We are not skilled to do comprehensive client review • Case management approach is needed and needs to be inclusive • Communication is often personality driven • Support mechanisms not available to encourage community integration eg community bus. • Waiting lists for allied health services are becoming a greater issue • HACC services are perceived as for aged people only • Younger persons with disabilities are not aware that they are included in accessing HACC services. • The aged and the young with disabilities do not mix well and younger people have no sense of connection to the community services. • Younger disabled have no power that can be channelled through a peak body and the elderly have a strong voice in the community. • Fragmenting of funding across the different services creates competitiveness • Difficult for staff in the field to negotiate funding with clients • Finance issues should not be a clinical function, should be administrative in nature external to all services and controlled by one person. • It can be difficult in a small community to explain differing dollar rates that people are entitled to. • Case management roles and responsibilities are a big issue with service providers and others doing the role and not being paid for it • Lack of case management skills and abilities across the Indigo shire is a big issue. • Blurred lines of referral systems that require evaluation. • Poor coordination of HACC services exist throughout the Indigo Shire • Services do not know who is doing what even between services and within services. • Referral systems between services create lengthy response times and the response to a referral may be two to three months. • HACC services are fragmented across Indigo shire • Has become a competitive environment where each service has to meet its targets, If targets are low then the clients is not referred to the appropriate service provider. • Lack of coordination in the health services across the shire.
HACC Service Review Indigo Shire 27
• Poor communication and coordination decreased quality of client care. • There is an opportunity for an external service to provide one referral and assessment pathway. That is one number and utilising the Scot tool for an intake process. • One person required to do assessments will create a more cohesive system for clients. • Need for a community clinician who does the assessment through the Scot tool and has an unbiased view of targets and it becomes client centred care – In other words a general intake worker. Create flexibility across all services after hours and weekends. • Poor knowledge of how HACC services work across the region creates differing perceptions from both clients and service providers of what HACC services actually provide. • There is information overload but at the same time not enough consistent HACC services information. • Poor communication and coordination decreases quality of client care
Note: In terms of the qualitative data the group were careful that language used by the participants in the workshops was not compromised in the interpretation and documentation of the summary.
HACC Service Review Indigo Shire 28
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