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
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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 .
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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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MERRI HEALTH / ANNUAL REPORT 2022 |
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35 |