Merri Health 2022 Annual Report | Page 37

THE COLLABORATIVE : WORKING TOGETHER FOR BETTER CARE
REDUCING HOSPITAL STAYS THROUGH COMMUNITY CARE
In September 2021 we launched a 12-month pilot program to reduce hospital readmissions for people experiencing Dyspnoea ( shortness of breath / difficulty breathing ) in partnership with the North Western Melbourne Primary Health Network , Royal Melbourne Hospital and cohealth .
The Collaborative is a partnership between the Royal Melbourne Hospital , North Western Melbourne Primary Health Network , cohealth and Merri Health .
The group formed in 2012 and works to create joint solutions to rising chronic illnesses rates and better care for our ageing population .
Projects have focused on : back pain , chronic health failure , chronic kidney disease , diabetes and digital health .
The Collaborative - Dyspnoea pathway pilot focused on identifying and linking patients with Congestive Heart Failure and / or Chronic Obstructive Pulmonary Disease with the supports they required to stay in the community on discharge , via a Merri Health ‘ Community Navigator ’.
What did we achieve ?
3 referrals on average per month
developed pathway support resources , including Community Navigator Program Guidelines and an evaluation framework
Where can we improve ?
• working as a collaborative team presented some challenges around referral pathways and cross-over of roles within the system . These areas have been identified and reviewed as part of the pilot transition to better support clients in the future
What ’ s next ?
• supporting clients to transition from the pilot into our Healthy Ageing services
• transition plan to end the pilot and collaborate on areas to improve services for our communities
HELPING AT-RISK CLIENTS MANAGE COMPLEX CONDITIONS
We continued to support clients with chronic heart failure and respiratory conditions to better manage their complex conditions in the community , improve their quality of life and reduce avoidable hospital admissions through our HARP Complex Care Service .
The multi-disciplinary service is provided in partnership with the Royal Melbourne Hospital ( RMH ), cohealth and Bolton-Clarke .
When the state-wide Code Brown was declared , our staff were redeployed to assist the RMH COVID monitoring program . They pivoted quickly and upskilled to deliver vital support where it was most needed .
What did we achieve ?
developed a new “ Home oxygen for post-COVID patients ” program
supported Royal Melbourne Hospital during the pandemic by redeploying our staff to the RMH Covid monitoring program
embedded exercise physiology in online group and face-to-face offerings
re-instated group programs which were disrupted due to the pandemic
What ’ s next ?
• continuing to help our clients manage their complex conditions in the community
• providing a range of groups , face-to-face appointments and home visits .
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