Quality of Care Report - Ballarat Health Services

HARPThe Hospital Admission Risk Program(HARP) at Ballarat Health Services is aDHS funded program that usespreventative models of care in order toimprove the health of peopleexperiencing chronic and complexhealth conditions.HARP aims to achieve this throughtargeting clients who are identified asfrequent hospital attendees or at risk ofhospitalisation, and who would mostlikely benefit from integrated andcoordinated care provided by the HARPCare Coordinators.All of the HARP clients on the chronicdisease streams have care plans.Services include:• Providing better services, informationand advocacy to clients and theirfamilies.• Ensuring that clients are treatedquickly at the earliest signs of changein their condition.• Provision of ongoing support andmonitoring for clients betweenhospital admissions.• Improved communication betweenthe client, hospital, GP andcommunity agencies.• Referral and linking of clients withappropriate services.• Incorporating the principles of selfmanagement into the overall aims ofthe program.HARP currently offers services for thefollowing groups:• People with chronic heart disease;• People with chronic respiratorydisease;• People with Diabetes;• Older people with complex needs(Falls);• People with complex psychosocialneeds; and• Currently HARP has a total of115 clients.The following client story reflects thelevel of service coordination,integration and support required toassist consumers in navigating theirway to better health outcomes.Linda Govan (left), HARP Manager with HARP staff Diane Lawson, Carmel Cunnington,Karen Brodie and Nola PoulterYour ExperiencePatient StoryThe client is a 67 year old male, with a history of Type 2 diabetes and heartdisease, who presented to the Emergency Department at BHS, after collapsingdue to low blood sugar (hypoglycaemia). The client also struggled with anxiety,related to living alone on an isolated property outside Ballarat, had limitedfamily support, and a fear of experiencing further hypoglycaemic events.English is also a second language for the client.Assessment occurred at the client’s home by the HARP Care Coordinator andindicated that the client did not have a GP in Ballarat, was not monitoring hisblood glucose levels and required podiatry and ophthalmology reviews.Outcomes:The HARP Care Coordinator organised the following services for the client:• Linked in with GP services at Ballarat Community Health Centre,Sebastopol;• Referral to Podiatry, Dietetics and Ophthalmology;• Referral to the National Diabetes Service Scheme (NDSS);• Purchase of a glucometer, with support and education initially providedby Ballarat District Nursing and Healhcare, funded through Post Acute Careat BHS;• Other support services organised included home help, shoppingassistance and Safety Link; and• The client was reviewed by Dr Andrew Kemp for HARP, with follow upprovided at the Diabetes Clinic at the Queen Elizabeth Centre.Concurrently, the HARP Care Coordinator also provided support with selfmanagement strategies, related to blood glucose monitoring, development ofan Action Plan with the client to assist with “sick day” management,assistance with medication adherence through improving symptommanagement and understanding, and reinforcement of dietary advice.Through involvement with HARP, the client now has regular contact with hisgeneral practitioner, is gaining confidence in symptom recognition andmanagement, has shown improved medication adherence and is generallymore confident in navigating his way through the health care service system.Ballarat Health Services Quality of Care Report 2007-08 22