Reducing respiratory and heart hospital admissions
We provide the Hospital Admission Risk Program ( HARP ) Complex Care service in partnership with The Royal Melbourne Hospital ( RMH ) and cohealth to help clients better manage their chronic heart failure and respiratory conditions in the community , and reduce avoidable hospital admissions .
The goal is for clients to manage their health independently at home and in the community .
HARP supports clients with care coordination , evidence-based care from nurses and allied health staff ,
1:1 home and community visits , weekly rehabilitation groups ; working closely with clinics at the RMH , the wider health system and community medical practitioners .
What did we achieve ?
35 patients successfully completed the pulmonary rehabilitation program . Of those clients :
– 88 % showed improvement in wellbeing and overall condition management
– 86 % reduced their Hospital Anxiety Depression Scale ( HADS ) depression score
– 71 % improved their 6 metre walk test
– 52 % reduced their HADS anxiety score
42 exercise sessions and
20 education sessions provided through our Pulmonary Rehabilitation Program
9 % overall increase on targets from last financial year
exceeded targets by 42 % for the CHF Program
exceeded targets by 26 % for the Respiratory Program
Where can we improve ?
the Diabetes Coordination Service transitioned from Merri Health to RMH , impacting the team . Through advocacy RMH has agreed to continue to provide local community services from our sites to limit the impact to our clients
What ’ s next ?
measuring outcomes and impact for clients from a clinical outcome perspective to demonstrate HARP ’ s clinical significance and community impact
working with RMH on model of care recommendations for the future , which will include demand increase for the service , increased complexity of the client cohort and supporting processes and infrastructure
Strengthening our prevention and chronic illness care model
We began the Prevention and Chronic Illness Care ( PCIC ) Model of Care project in 2021 . Through it we are identifying the strengths of our work in this area , and opportunities for improvement so that we can continue to support clients with best practices in the future .
We work to deliver our services in line with evidence-based care and treatment for people in our community who are at risk of or who have existing health and chronic conditions . This support targets a wide range of client needs , including musculoskeletal conditions , diabetes and respiratory and cardiac conditions .
Alongside continuing to provide person-centered care , this year we have focused on improving key PCIC processes . We have implemented an integrated initial needs assessment , case conferencing , and risk stratification , and captured data to monitor the success rate of our changes and their benefits to our clients .
What did we achieve ?
integrated Initial Needs Assessment embedded into PCIC practice
commenced case conferencing
created monitoring systems to assess our service improvements , including an evaluation template and pending dashboard
Where can we improve ?
continuing to provide the very best care while also implementing changes to PCIC processes and procedures
What ’ s next ?
continuing to embed the identified changes to PCIC processes and monitor the improvements via our dashboard
developing a satisfaction survey to measure self-reported experiences from PCIC clients
Merri Health Annual Report 2023 49